                     IN THE COURT OF APPEALS OF IOWA

                                    No. 14-1954
                              Filed February 24, 2016


IN THE MATTER OF S.B.,
Alleged to be Seriously
Mentally Impaired

S.B.,
     Respondent-Appellant.
________________________________________________________________

        Appeal from the Iowa District Court for Madison County, Randy V. Hefner,

Judge.



        S.B. appeals a district court ruling affirming her continued involuntary

commitment to a residential care facility. AFFIRMED.



        Cami N. Eslick of Eslick Law, Indianola, for appellant.

        Thomas J. Miller, Attorney General, and Gretchen Witte Kraemer,

Assistant Attorney General, for appellee.



        Considered by Vogel, P.J., and Vaitheswaran and Bower, JJ.
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VAITHESWARAN, Judge.

       S.B. appeals a district court ruling affirming her continued involuntary

commitment to a residential care facility. She argues the court’s finding that she

remains “seriously mentally impaired” is not supported by substantial evidence.

I.     Background Facts and Proceedings

       This case began with an application to involuntarily hospitalize S.B. based

on her threats of self-harm. A magistrate ordered S.B. placed at the Clarinda

Mental Health Institute.

       S.B. was released to outpatient care but concerns with her behavior led to

an order transitioning her to a residential care facility.   She remained in the

facility for several years.   During the fourth year of her stay, the magistrate

ordered continued inpatient treatment at the same facility. S.B. contested the

order and requested a placement hearing. See Iowa Code § 229.14A(1) (2015)

(setting forth “respondent’s right to request a placement hearing to determine if

the order for placement or transfer of placement is appropriate”).      The court

granted the request for a hearing and subsequently confirmed the prior findings

and orders. S.B.’s appeal of the ruling was dismissed as untimely.

       Two months later, the magistrate entered another order reaffirming S.B.’s

residential placement at the same facility. S.B. again contested the magistrate’s

findings and requested another placement hearing.            The magistrate again

confirmed the placement after concluding S.B. was “mentally ill, and said mental

illness ma[de] her a danger to herself or others.”
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        S.B. timely appealed this decision to the district court, which held a de

novo trial pursuant to Iowa Code section 229.21(3)(c). The court affirmed the

magistrate’s order. This appeal followed.

II.     Sufficiency of the Evidence

        S.B. challenges the sufficiency of the evidence supporting the district

court’s findings. The Iowa Supreme Court has stated, “[T]he elements of serious

mental impairment must be established by clear and convincing evidence and

the district court’s findings of fact are binding on us if supported by substantial

evidence.” In re J.P., 574 N.W.2d 340, 342 (Iowa 1998). Accord In re B.B., 826

N.W.2d 425, 428, 432 (Iowa 2013); see also In re Oseing, 296 N.W.2d 797, 801

(Iowa 1980) (“The substantial evidence test governs review of trial court findings

of fact.”).

        A person is “seriously mentally impaired” if the person has

        mental illness and because of that illness lacks sufficient judgment to
        make responsible decisions with respect to the person’s hospitalization or
        treatment, and who because of that illness meets any of the following
        criteria:
        (a) Is likely to physically injure the person’s self or others if allowed to
        remain at liberty without treatment.
        (b) Is likely to inflict serious emotional injury on members of the person’s
        family or others who lack reasonable opportunity to avoid contact with the
        person with mental illness if the person with mental illness is allowed to
        remain at liberty without treatment.
        (c) Is unable to satisfy the person’s needs for nourishment, clothing,
        essential medical care, or shelter so that it is likely that the person will
        suffer physical injury, physical debilitation, or death.

Iowa Code § 229.1(17).        This definition contains three elements: (1) mental

illness, (2) lack of sufficient judgment, and (3) the criteria labeled (a), (b), and (c),
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which encompass the threshold requirement of dangerousness.          Oseing, 296

N.W.2d at 800-01 (analyzing predecessor statute).

       S.B. “does not dispute that she has a mental illness.” She challenges the

evidence supporting the district court’s findings on the “lack of sufficient

judgment” element and the dangerousness components.

A.     Lack of Judgment

       As a preliminary matter, the State argues S.B. waived a challenge to this

element. We disagree. Although S.B. did not set forth a separate brief point on

“lack of judgment,” her argument encompasses this ground. See In re Mohr, 383

N.W.2d 539, 541-42 (Iowa 1986) (finding the respondent’s denial of treatment “in

the face of a conclusive showing that he has a serious need for help” relevant to

the “lack of judgment” element). Accordingly, we proceed to the merits.

       The “lack of judgment” element “requires the State to prove that the

person is unable because of the alleged mental illness, to make a rational

decision about treatment, whether the decision is to seek treatment or not.” In re

B.T.G., 784 N.W.2d 792, 797 (Iowa Ct. App. 2010). The record before the district

court reveals the following facts.

       S.B. has a long history of noncompliance with her medication regimen.

For example, in 2012, she refused an anti-psychotic medication twenty-nine

times within a two month period.     The residential care facility addressed her

refusals by barring her from leaving the facility for two months each time she

violated medical protocol.      S.B.’s compliance improved and, in the year
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preceding the district court hearing, she only declined her medications three

times.

         Nonetheless, S.B. refused medication just two weeks before the district

court hearing. Although she ultimately took the medicine the next morning, she

commented that her refusal would “buy [her] more time in the facility.” Notably,

S.B. had six days of accrued leave she could have used outside the facility. A

reasonable fact finder could have found her reason for refusing medication

reflected poor judgment.

         Professionals uniformly confirmed S.B.’s lack of judgment on treatment

issues. A psychiatric nurse practitioner who treated S.B. opined that her insight

concerning the importance of taking her medication “would erode” outside the

facility and “then you would have quite a difficulty,” given her past “suicidal

thoughts and psychotic symptoms.”           Similarly, a health professional who

evaluated S.B. reported that she showed “significant concerns . . . in being able

to manage her medications for both psychotropic and medical issues.” Finally,

the facility administrator testified S.B. “would probably regress quite quickly

outside” the controlled environment of the facility. She opined, “[I]f she refuses

[her medication] here, what will she do if she’s not held accountable by nobody?”

The district court appropriately gave weight to these opinions. See In re R.S.,

No. 15-0713, 2015 WL 7574238, at *2 (Iowa Ct. App. Nov. 25, 2015) (upholding

finding where “physician’s report and the treating doctor’s testimony each

establish the same”); In re S.S., No. 15-0494, 2015 WL 6508809, at *5 (Iowa Ct.

App. Oct. 28, 2015) (finding lack of judgment established where “[i]t was the
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judgment of each examining doctor that [respondent] was not capable of making

responsible decisions with respect to hospitalization or treatment”).

       In light of this evidence, the district court reasonably could have given little

credence to S.B.’s recognition that she would need to take medications “for the

rest of [her] life.” See In re B.T.G., 784 N.W.2d at 798 (“Although [respondent]

has indicated he will comply with his medications, we cannot find his testimony

persuasive given his lengthy history of noncompliance and resistance.”). The

court could have questioned S.B.’s sincerity based on her reluctance to continue

taking the single anti-psychotic drug that her health care provider testified was

the “gold standard” for treatment of her condition. As for S.B.’s reliance on her

overall compliance with her medication regimen while on leave, the court could

have found S.B. followed her regimen for fear of losing future leave and, without

this “stick,” her compliance would have faltered.

       We conclude substantial evidence supports the district court’s finding of

lack of judgment.

B.     Dangerousness

       As noted, the statute contains three components of dangerousness and

the State only needs to satisfy one. See Iowa Code § 229.1(17). We will focus

on the third component, whether the person with mental illness is “unable to

satisfy the person’s needs for nourishment, clothing, essential medical care, or

shelter so that it is likely that the person will suffer physical injury, physical

debilitation, or death.”   Id. at 229.1(17)(c). Within this list, the only need of
                                        7



concern is “essential medical care.” Id. The State must establish a “recent overt

act, attempt, or threat.” Mohr, 383 N.W.2d at 542.

       The district court concluded, “Given [S.B.]’s array of physical and mental

ailments requiring medication, a failure to manage her medication would likely

result [in] harm to her.” The record contains substantial evidence to support this

finding.

       We have already documented health care professionals’ recent concerns

about whether S.B. would continue with mental health treatment if she were living

independently. Additionally, they expressed doubts about her ability to treat a

potentially fatal physical condition—type I diabetes. The facility administrator

testified S.B.’s “diabetes would be out of control” if she discontinued her

medication. While she acknowledged S.B. had never been hospitalized for this

condition while on leave, she described S.B.’s blood sugars as both elevated and

too low at various times.   She testified, “I don’t know that [S.B.] can always

understand what she’s doing to herself that causes that high or low [blood

sugar].”

       This testimony found support in the notes of a psychiatric registered nurse

practitioner who interviewed S.B.    According to her documentation, just two

months prior to the hearing S.B. could not list the medications she took and

admitted to having a very poor memory. And, as noted, S.B. refused medication

just two weeks before the district court hearing. Finally, in her own testimony,

S.B. failed to demonstrate either insight into, or an ability to manage, her

diabetes.
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       The district court reasonably could have found that S.B.’s reluctance to

continue with the mental health regimen prescribed by her health care providers

and her medication refusal two weeks prior to the hearing, when combined with

her lack of understanding about the need to follow a strict medical regimen for

her diabetic condition, jeopardized her health and satisfied this dangerousness

component.

       We conclude substantial evidence supports the district court’s finding of a

“serious mental impairment.” Accordingly, we affirm the ruling continuing S.B.’s

involuntary commitment at the residential care facility.

       AFFIRMED.
