J.H. v. Prince George's Hosp. Ctr.

CourtCourt of Special Appeals of Maryland
Citation165 A.3d 664,233 Md.App. 549
Docket NumberNo. 1056, Sept. Term, 2016,1056, Sept. Term, 2016
Decision Date27 July 2017

Argued by: Rachel Simmonsen (Paul B. DeWolfe, Public Defender, on the brief), Baltimore, MD, for Appellant.

Argued by: Douglas C. Meister (Gina M. Smith, Meyers, Rodbell & Rosenbaum, on the brief), Riverdale Park, MD, for Appellee.

Panel: Leahy, Reed, Lawrence F. Rodowsky (Senior Judge, Specially Assigned), JJ.

Leahy, J.Suffering from the harmful effects of mental illness, J.H., C.B., M.G., and B.N. (collectively "Appellants"), were brought to Prince George's Hospital Center1 ("Appellee" or the "Hospital") on separate occasions for emergency mental health evaluations to determine whether each should be admitted for involuntary psychiatric treatment. Each Appellant was afforded a hearing before an administrative law judge ("ALJ"), during which their counsel argued for their release on the ground that the Hospital failed to comply in various respects with the preadmission procedures set out in Maryland Code (1982, 2015 Repl. Vol.), Health–General Article ("Health–Gen."), § 10–601 et seq.2 Each ALJ concluded the evidence established that Appellants qualified for involuntary admission to the Hospital's inpatient psychiatric unit in accordance with Health–Gen. § 10–632(e), and that none of the alleged preadmission procedure violations warranted Appellants' release.

Counsel filed a petition for judicial review for each Appellant and a motion to consolidate their cases in the Circuit Court for Prince George's County. The circuit court granted the motions to consolidate and, after argument, affirmed the ALJs' decisions with respect to each Appellant.

Before this Court, Appellants challenge the ALJs' decisions and present issues3 derivative of one overarching question: During involuntary admission hearings are hospitals required to affirmatively prove compliance with preadmission procedures beyond the statutorily prescribed involuntary admission elements contained in Health–Gen. § 10–632(e) ?

For the reasons that follow, we affirm the decisions ordering the involuntary admission of each Appellant. We hold that at an involuntary admission hearing, the Hospital has the burden to prove the involuntary admission elements enumerated in Health–Gen. § 10–632(e) by clear and convincing evidence, and that the patient has the burden, pursuant to Code of Maryland Regulations ("COMAR"), to raise with particularity any alleged violations of preadmission procedures. Once raised, the burden shifts to the Hospital to demonstrate, by a preponderance of the evidence, its compliance with the particular procedural violations raised.

A. Involuntary Admission Hearings

The following is a summary of the testimony presented at each hearing and the ALJ's findings as to each Appellant.

1. J.H.'s Involuntary Admission Hearing

Before J.H. was involuntarily admitted into the psychiatric unit at the Hospital, she lived with her daughter, K.H., and her two-year-old granddaughter. K.H testified that she witnessed her mother's ability to care for herself decline over the last several years. J.H. was not taking her medications for her psychiatric and other medical conditions, and refused to attend scheduled doctors' appointments. After her mother became "very aggressive and verbally abusive," K.H. filed a petition for the emergency evaluation of J.H. on September 2, 2015. That same day, the police brought J.H. to the Hospital's emergency room for evaluation.

On September 16, 2015, an ALJ held an involuntary admission hearing for J.H. At the outset of the hearing, J.H.'s counsel stated that he "[would] be bringing up that the notice of admission status and the detention in the emergency room both exceeded the time limits[.]"

Dr. Prasad, J.H.'s treating physician, testified for the Hospital. In regard to J.H.'s eligibility for admission under Health–Gen. § 10–632(e)(2)(i)-(v) —the controlling statute in this case—Dr. Prasad testified that J.H. has been diagnosed with chronic schizophrenia

, diabetes, and hypertension. She had been admitted to the Hospital several times during the year-and-a-half prior to the hearing. He explained that upon discharge, J.H. would refuse to comply with her treatment regimen of psychiatric medication and outpatient care, resulting in her readmission. J.H. failed to maintain her personal hygiene, often stayed in bed, and only occasionally ate meals. Dr. Prasad presented J.H. with the option to voluntarily admit herself, but she refused because she was unable to "appreciate[ ] the nature of her mental illness and need for current treatment." He testified that J.H. also refused to accept outpatient treatment for her mental illness and medical conditions, which, if left untreated, posed a considerable threat to her health. In Dr. Prasad's professional opinion, J.H. needed institutional care and there was no less restrictive treatment available for her.

Next, Dr. Prasad testified that J.H. was certified by two physicians and given notice of her admission status. He did not know how long J.H. waited in the emergency room and said that he would need to "look in the record" for that information. Neither counsel revisited this open issue. In fact, on cross-examination, J.H.'s counsel asked only one question: "How did my client get to the hospital, Doctor?"

K.H. testified that she could not provide the care J.H. required and that J.H. could no longer live with her. K.H. also raised a concern regarding her two-year-old daughter's safety, referencing J.H.'s cavalier attitude toward storing and disposing of her prescription medications in places accessible by the child.

After the conclusion of the Hospital's case, J.H's counsel moved to have her released. He alleged that J.H.'s involuntary admission hearing was not conducted within 10 days of J.H.'s initial confinement. He also stated that the Hospital failed to demonstrate when the certifications were completed, or when the Hospital gave J.H. notice of her admission status, or how long J.H. was in the emergency room. Because the Hospital failed to comply with the applicable preadmission procedures, counsel for J.H. argued the ALJ was deprived of jurisdiction to conduct the involuntary admission hearing.

The ALJ denied J.H.'s motion for release, finding that although "the time periods aren't really crystal clear ... [J.H.] is having her hearing in a timely fashion."

J.H. was the only witness offered in support of her case. J.H. testified that she intended to continue with her outpatient psychiatric and medical treatment, but she no longer required medication for schizophrenia

or diabetes. Her primary reason for no longer taking Haldol—a prescription for schizophrenia—was the unpleasant side-effects. As for the medication for her other medical conditions, J.H. said she no longer had diabetes or high blood pressure because "[she] lost about 79 pounds and that put [her] sugar right."

With respect to the alleged preadmission procedure violations, the ALJ declined to make a finding on J.H.'s admission date because "[h]er admission date wasn't testified to[.]" Then the ALJ made express findings for each involuntary admission element the Hospital is required to prove pursuant to Health–Gen. § 10–632(e)(2)(i)-(v).4 First, the ALJ found that J.H. "has a mental disorder diagnosed as schizophrenia

chronic." Second, the ALJ determined that J.H. requires inpatient care and treatment. Regarding the third element, the ALJ found that although J.H. "is mentally ill and unpredictable, [ ] she hasn't really done anything to anybody ... that would make her dangerous to others." But he did find that she posed a danger to herself, reasoning that he did not

... believe the patient's testimony that she is no longer diabetic. Her daughter testified that she has chronic kidney disease

, which is often caused by diabetes. She also has hypertension, and the diabetes, both of which ... can kill you if they're not controlled and treated.

Not bathing, not eating, the patient doesn't look like she's starving, but ... not taking your medication for medical conditions, thinking that you don't have these medical conditions, which are serious and life threatening, does threaten your own life and safety and it's caused by [J.H.'s] mental illness.

Fourth, he concluded that J.H. was "unwilling and unable to be voluntarily admitted." Lastly, the ALJ reasoned that "there [wa]s no less restrictive form of intervention for her [based on] Dr. Prasad's testimony about her continued history of being discharged and not taking medication and relapsing." After reciting his findings, the ALJ ordered the involuntary admission of J.H.

2. C.B.'s Involuntary Admission Hearing

Before C.B. was involuntarily admitted into the psychiatric unit at the Hospital on September 12, 2015, she lived alone. A.B., her father, testified that although he and her mother helped C.B. with cutting the grass and grocery shopping, C.B. was not able to maintain the cleanliness of her home. On one visit, A.B. noticed that dirt was visible on the floors and the kitchen sink was clogged and the "water smell[ed] like it [had] been in there for three months." A.B. became increasingly concerned for his daughter's wellbeing after one shopping trip she went on with her mother. Apparently C.B. opened the car door while the car was moving and got out. A.B. also explained that one grocery store banned C.B. for three years after an incident in which she became verbally aggressive with other store patrons. After observing C.B.'s "gradual deterioration," C.B.'s parents filed a petition for emergency evaluation on September 11, 2015, and brought her to the Hospital.

On September 16, 2015, an ALJ held an involuntary admission hearing to determine whether C.B. should be involuntarily admitted for psychiatric treatment. C.B. was not present at the hearing. At the outset of the hearing, C.B.'s counsel requested her release,...

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