In the Matter of R.B., Alleged to Be Seriously Mentally Impaired

IN THE COURT OF APPEALS OF IOWA

No. 23-1336
Filed April 10, 2024

IN THE MATTER OF R.B.,
Alleged to Be Seriously Mentally Impaired,

R.B.,
Respondent-Appellant.
________________________________________________________________

Appeal from the Iowa District Court for Marshall County, Bethany Currie,

Judge.

R.B. appeals the district court’s order finding him to be seriously mentally

impaired and determining his placement. AFFIRMED.

Laura A. Eilers of Peglow, O’Hare, See & Eilers, P.L.C., Marshalltown, for

appellant.

Brenna Bird, Attorney General, and Sarah Jennings, Assistant Attorney

General, for appellee State.

Considered by Ahlers, P.J., Buller, J., and Gamble, S.J.*

*Senior judge assigned by order pursuant to Iowa Code section 602.9206

(2024).
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GAMBLE, Senior Judge.

In July 2009, R.B. was found to be seriously mentally impaired, a

determination that has been confirmed regularly by evaluating psychiatrists. R.B.

is currently in residential care at the Iowa Veterans Home in Marshalltown. R.B.

appeals a district court order affirming he is seriously mentally impaired and his

placement. He challenges whether he continues to be seriously mentally impaired

and his current placement as the least-restrictive placement. “We review

challenges to the sufficiency of the evidence in involuntary commitment

proceedings for errors at law.” In re B.B., 826 N.W.2d 425, 428 (Iowa 2013). “The

elements required for an involuntary commitment must be established by clear and

convincing evidence,” and we are bound by the district court’s fact findings “if

supported by substantial evidence.” In re V.H., 996 N.W.2d 530, 536 (Iowa 2023)

(citation omitted).

R.B. has appealed his commitment twice before. In 2014, he appealed his

placement at the Iowa Veterans Home; the district court and this court affirmed the

finding of continuing serious mental impairment and the placement. In re R.B.,

No. 15-0823, 2015 WL 6507836, at *1 (Iowa Ct. App. Oct. 28, 2015) (noting R.B.’s

condition was not improving at that time). Just over four years later, R.B. petitioned

for a writ of habeas corpus, which the district court and then this court denied. In

re R.B., No. 19-2044, 2020 WL 7021787, at *2 (Iowa Ct. App. Nov. 30, 2020). In

that case, while we recognized some evidence in R.B.’s favor regarding whether

he posed a danger to himself, substantial evidence in the form of an overt act of

his drinking eleven beers in thirty minutes and a history of not attending follow-up
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mental-health appointments supported the district court’s conclusion R.B. was

likely to injure himself or others if released from commitment. Id. at *1-2.

A. Seriously Mentally Impaired.

Iowa Code section 229.1(22) (2023) defines “seriously mentally impaired”

as

the condition of a person with 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.
d. Has a history of lack of compliance with treatment and any
of the following applies:
(1) Lack of compliance has been a significant factor in
the need for emergency hospitalization.
(2) Lack of compliance has resulted in one or more acts
causing serious physical injury to the person’s self or others
or an attempt to physically injure the person’s self or others.

Our courts have broken this down into three elements: (1) a mental illness,

(2) judgment impairment as to treatment, and (3) a danger posed to self or others.

See V.H., 996 N.W.2d at 543. The danger posed is predictive in nature but must

“be evidenced by a recent overt act, attempt, or threat.” Id. (cleaned up). R.B.

only argues the danger element was not proven by clear and convincing evidence,

he does not challenge the other elements.

R.B. has been diagnosed with several mental-health issues—including

schizophrenia, anxiety, a neurocognitive disorder following a 2010 traumatic brain
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injury, and others. He takes prescription medications to manage his symptoms.

R.B.’s medications are managed by a nurse practitioner in the Veterans Home,

and the Veterans Affairs (VA) psychiatrist reviews his records regularly. R.B. has

refused treatment with the VA’s psychiatrist since 2019 after the doctor continued

to recommend treatment at the Veterans Home instead of independent living. R.B.

stated the psychiatrist “gets me more depressed,” so he doesn’t bother talking to

him.

R.B. testified on his own behalf. Although he was unaware of the doses of

his medication, he stated he would comply with his medication to get out of the

facility. He appeared to believe his past alcohol abuse was the primary reason for

his placement at the Veterans Home. When questioned about his plans outside,

he mentioned fishing, hunting, and seeing his siblings. He agreed with one of his

prior statements that he would like to get an RV and travel across the country. 1

Even without the RV, R.B. planned to travel and see the country and visit family

and friends. He talked about writing letters to celebrities he is convinced are his

children and claimed to have “over ten” children.2

In July 2022, R.B. was evaluated by an independent psychiatrist in regards

to his continued commitment at the Veterans Home. He told the independent

psychiatrist he didn’t need his medications because he doesn’t have a mental

1 At a prior hearing, R.B. admitted his drivers license had lapsed and he had not

renewed it because he is not allowed a car at the Veterans Home. Nothing in the
record indicates he has since gotten his license back.
2 At an earlier hearing, the VA psychiatrist attributed these beliefs to R.B. having

“residual effects from schizophrenia” despite the general effectiveness of his
treatment. R.B.’s paranoia and delusions worsened for a time, leading to an
increase in medication dosage in 2018. His dose has been stable since then.
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illness. The evaluating psychiatrist recommended R.B. remain at the Veterans

Home as the least restrictive placement, noting his need for structure and opining

R.B. would not comply with his medication without supervision and likely injure

himself or others.

The VA psychiatrist testified, emphasizing the importance of a structured

environment and supervision for R.B.’s continued sobriety and medication

management. He opined if on his own, R.B. was likely to start using alcohol again,

which combined with his cognitive impairment would result in a failure to take

medication as prescribed, leaving him at risk for severe and unmanageable

delusions and hallucinations. Further, without adequate supervision, the

psychiatrist doubted R.B. would be able to adequately satisfy his needs for

nourishment, shelter, and medical care. The psychiatrist noted R.B., who was

seventy years old at the hearing, is entering an age group where dementia is more

common, and he is at a much higher risk due to past traumatic brain injury and

past alcohol abuse.

R.B. argues the evidence fails to establish a recent overt act, attempt, or

threat sufficient to justify placement at the Veterans Home. See V.H., 996 N.W.2d

at 543 (requiring “a predictive judgment, based on prior manifestations but

nevertheless ultimately grounded on future rather than past danger” (citation

omitted)). Past instances of overt acts include that in 2014, he became intoxicated,

threw away his medication, fell, and injured himself. In 2017, R.B. had an

altercation with a peer at the Veterans Home. In 2019, he drank eleven beers in

thirty minutes when briefly unsupervised while visiting family. There have been no

more recent incidents because R.B. has been stable, consistently medicated, and
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monitored for alcohol use while under the care of the providers at the Veterans

Home. R.B.’s past performance is predictive of what is likely to occur if R.B is

released to a less restrictive environment, either living on his own or with someone

who has not demonstrated an ability to provide the care and supervision he needs.

R.B.’s lack of insight into his condition—particularly not believing he has any

mental illness requiring medication and a demonstrated inability to distinguish

between his delusions and reality even when medicated—makes it likely that he

would injure himself or others in the future if allowed to remain at liberty without

treatment. See id. We further observe that his plan for living outside the Veterans

Home is entirely dependent on a friend who has not affirmed to anyone else she

is willing and able to help R.B. meet his needs for “nourishment, clothing, essential

medical care, or shelter” in a manner that does not put him or any other person at

risk of harm. See Iowa Code § 229.1(22)(c); In re C.B., No. 22-2089, 2023

WL 3092076, at *3 (Iowa Ct. App. Apr. 26, 2023) (discussing an expressed

reluctance to take medication and reliance on another for food, shelter, and

medical compliance as recent overt acts).

Based on this record, we find R.B. does have a mental illness. See Iowa

Code § 229.1(22); V.H., 996 N.W.2d at 543. As he denies having a mental illness,

he lacks “sufficient judgment to make responsible decisions with respect to” his

treatment. See Iowa Code § 229.1(22); V.H., 996 N.W.2d at 543. And substantial

evidence supports the district court’s finding that without adequate medication

management, “[h]e would likely inflict physical injury on himself or others if placed

in a less restrictive environment.”
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B. Least Restrictive Placement.

R.B. also requests a less-restrictive placement than the Veterans Home and

to be treated on an outpatient basis. “It is not only the customary procedure, but

the constitutionally and statutorily mandated requirement, to treat even seriously

mentally impaired persons in the least restrictive environment medically possible.”

In re E.H., No. 02-1786, 2003 WL 22190913, at *9 (Iowa Ct. App. Sept. 24, 2003)

(citation omitted); see Iowa Admin. Code r. 441-29.5(3)(a).

R.B. is at a “residential level of care” at the Veterans Home. This is “a fairly

low level of care where he is free to go to stores or restaurants, whatever. He’s

not under lock and key. He just has a certain degree of structure and supervision

so that he has assistance available if he needs it.” R.B. has to notify staff where

he is going and needs permission if he plans to stay elsewhere overnight. The VA

psychiatrist opined if R.B. were to leave the facility, any caregiver would need to

be able to provide “pretty much around-the-clock supervision” not only to monitor

R.B.’s sobriety and medication, but also to be available in case complications

developed on an outing.

R.B. suggested a friend he could live with in Waterloo. According to R.B.,

they had agreed on rent, and she would help with his transportation. He planned

on going to fast food restaurants for his meals. A mental-health advocate

contacted R.B.’s suggested landlady but was unable to finish the conversation

after the phone cut off. The friend did not return or finish the phone call and has

not contacted the Veterans Home to make arrangements for her home to be

checked or to arrange for R.B. to move in.
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R.B. has done well in his structured placement, where he has freedom in

the community, his basic needs provided for, his medications tracked, and

resources available at all times. There is no evidence his suggested placement

has the ability to provide any level of supervision or ensure R.B. complies with his

medication treatment. Based on these facts, the Iowa Veterans Home is the least

restrictive placement appropriate for R.B. We conclude clear and convincing

evidence supports the district court’s order.

AFFIRMED.