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J.H. v. Prince George's Hospital Center

Court of Special Appeals of Maryland

July 27, 2017

J.H., ET AL.

         Circuit Court for Prince George's County Case Nos. CAL15-25618, CAL15-25619, CAL15-25620, CAL16-00341

          Leahy, Reed, Rodowsky, Lawrence F., (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 Center[1] ("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 issues[3]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, vaguely asserting there was an error in the emergency petition and notice of admission.

         The Hospital called as its witnesses Dr. Mirmirani, director of psychiatric services and C.B.'s treating physician, and A.B. Dr. Mirmirani testified to the circumstances of C.B.'s admission and emergency evaluation. When evaluating C.B., Dr. Mirmirani was not able to have a meaningful conversation with C.B. regarding voluntary admission because "she [wa]s very psychotic, very preoccupied, refused to engage in conversation[, ]" and "she has . . . no insight, very poor judgment about her psychiatric condition[.]" Dr. Mirmirani confirmed that two physicians signed the certification and that C.B. was notified of her rights and refused to sign the consent as reflected in the following testimony:

[By counsel]: . . . Before you is the petition for emergency evaluation filed by [C.B.'s] father?
Dr. Mirmirani: That's correct.
[By counsel]: And the date of that petition?
Dr. Mirmirani: Is 9/11/2015.
[By counsel]: Okay. Does the record reflect that she was given her notification of admission status and rights?
Dr. Mirmirani: Yes, ma'am.
[By counsel]: Did she sign it?
Dr. Mirmirani: She refused to sign.
[By counsel]: Thank you. Could you please read what - what it says? What the completer of this document had [sic] wrote?
Dr. Mirmirani: Yes. She said she refused, is paranoid, and she "said she was tricked."
* * *
[By counsel]: Does the record reflect that two qualifying physicians did the certifications for [C.B.]?
Dr. Mirmirani: Yes, ma'am.
[By counsel]: Was [C.B.] given her notice of hearing today?
Dr. Mirmirani: Yes. Yes, ma'am.
[By counsel]: Does the record reflect that?
Dr. Mirmirani: Yes, ma'am.

         Dr. Mirmirani then testified to the Health-Gen. § 10-632(e)(2)(i)-(v) involuntary admission elements. Dr. Mirmirani indicated that C.B. was diagnosed with chronic schizophrenia. Dr. Mirmirani prescribed anti-psychotic medication to C.B., but she refused to take the medication. He testified that C.B. "walk[s] around . . . talking to herself" and is "under the influence of internal stimuli . . . which is a psychotic process that she's responding [to] and . . . [she] continues to be psychotic." Although she had wandered to the neighbor's home and the shopping center and caused a disturbance, Dr. Mirmirani testified that he did not believe C.B. presented a risk to others. However, Dr. Mirmirani opined that C.B. was a danger to herself because she had lost a lot of weight, was not eating, and was preoccupied with her "internal psychotic process." He also opined that C.B. required institutional treatment because she was not caring for herself and her psychosis rendered her "incapable of even believing that she has mental illness and needs treatment." Based on C.B.'s six or seven year history of mental illness and severe psychosis, Dr. Mirmirani testified that there was no less restrictive alternative.

         On cross-examination, C.B.'s counsel inquired into the alleged procedural error in the petition filed by C.B.'s father:

[C.B.'s counsel]: Doctor, you mentioned there's an emergency petition. The question number 10 on the emergency petition which says the petitioner or the person to be evaluated is a danger. What does it say as to what her danger is?
Dr. Mirmirani: Well, it says she's disturbing the neighbors - -
[C.B.'s counsel]: Is that number 9, Doctor, or is - -
Dr. Mirmirani: Number 10, I'm sorry.
[C.B.'s counsel]: Number 10, her dangerousness, it says is not applicable.
Dr. Mirmirani: Not applicable.

         C.B.'s counsel then asked a set of questions, presumably to show that C.B.'s name and status did not appear on the notice of admission status form. Dr. Mirmirani clarified on redirect, however, that the patient's first name was at the end of the notice of admission status form, where, below the nurse's signature it read "I certified that I have informed [C.B.] of his or her admission status and rights [in] accordance with the provision of Health General Article 10 and Criminal Procedure Article, Notice of Admission." During the hearing, C.B.'s father also testified that his daughter posed a danger to herself and others, and the "not applicable" "could have been a mistake."

         After the close of the Hospital's case, C.B.'s counsel did not call any witnesses and proceeded directly to closing arguments. C.B.'s counsel demanded C.B.'s release, reasserting that there was an error in the emergency petition because it did not state how C.B. was a danger to others, and alleging generally that the Hospital did not prove compliance with all relevant preadmission procedures. He also argued, for the first time, that there was no evidence that the petition had been presented to a judge, or that Dr. Mirmirani saw C.B. within 48 hours of her admission.

         The ALJ denied C.B.'s motion for release, finding that the Hospital demonstrated that the proper procedures were followed. The ALJ noted that no one from the patient's side testified to any alleged errors, and that "if the patient wishes to challenge [the Hospital's compliance with preadmission procedures], it's up to the patient to present evidence that the procedures were not, in fact, followed and that the error was of severe magnitude to require release because no other remedy would be sufficient and that has not been done in this case." With respect to the alleged error in the petition, the ALJ determined the error did not require C.B.'s release because the petition was completed by A.B. and noted that "I'm willing to assume that [the petition] was summoned by a judge because [A.B.] doesn't have any authority to [] have the police or the sheriff pick up his daughter off the street and bring her into - - to an emergency room for evaluation. When a civilian fills out that petition, the court has to approve it."

         Next, the ALJ made express findings for each involuntary admission element enumerated in Health-Gen. § 10-632(e)(2)(i)-(v). First, the ALJ found that C.B has chronic schizophrenia. Then, he determined that C.B. required institutional care and treatment. With respect to the third element, the ALJ found that C.B. was a danger to herself because of her inability to care for herself, and because she "got out of a moving car" and was so "disruptive and hostile" that a grocery store banned her. Fourth, he concluded that C.B "is unwilling to be voluntarily admitted." Lastly, the ALJ determined that

there is no less restrictive form of intervention that's available for her that's consistent with her welfare because she does not cooperate with mental health professional[s] except when she's forced to in a hospital.
Dr. Mirmirani said his plan is to take her to a clinical review panel and have her involuntarily medicated if necessary. [A.B.] testified that she hasn't seen an outpatient psychiatrist or taken her medications in the last six months at least and certainly she has decompensated.

         After reciting his findings, the ALJ ordered the involuntary admission of C.B.

         3. M.G.'s Involuntary Admission Hearing

         A police officer found M.G. on the street, walking shoeless in traffic. She appeared confused and was almost hit by a car. The officer brought M.G. to the emergency room of the Hospital and filed an emergency petition for M.G.'s involuntary admission in September 2015.[5] On September 16, 2015, an ALJ held an involuntary admission hearing for M.G. In his opening statement, M.G.'s counsel alleged the Hospital violated the preadmission procedures by keeping M.G. in the emergency room for 41 hours.

         The Hospital called Dr. Mirmirani, the director of psychiatric services and M.G.'s treating physician, as its only witness. Dr. Mirmirani diagnosed M.G. with substance-induced psychosis[6] and psychotic chronic mental illness. M.G. may have had an additional mental illness, according to Dr. Mirmirani, however, M.G. was unable to relate her medical history.

         On admission, M.G. was psychotic and agitated. The Hospital staff had to restrain M.G. and administer medication intramuscularly. On the day of the hearing, M.G. was still experiencing psychosis but had agreed to voluntarily take the prescribed antipsychotic medication. Despite M.G.'s improvement-resulting from the medication and treatment- Dr. Mirmirani testified that M.G. did not agree to voluntarily admit herself and that she "[had] very poor judgment about the need for psychiatric care at this time." Dr. Mirmirani testified that M.G. was a threat to her own safety because the officer found her incoherent, walking in the street and that she was still experiencing psychosis at the time of the hearing. He opined that M.G. requires institutional care and treatment for daily monitoring to stabilize her psychosis and to accurately diagnose her additional mental illnesses.

         M.G.'s counsel did not call any witnesses, moved to release M.G., and argued in closing that M.G.'s time in the emergency room exceeded the statutorily prescribed time, and "[t]here's no evidence that [M.G.] . . . was ever certified here, whether [M.G.] was ever given notice of her admission status, [and notice] of this hearing." Maintaining that the preadmission procedures are jurisdictional, M.G.'s counsel argued that she must be released unless the Hospital could demonstrate that it complied with the preadmission procedures.

         The ALJ agreed that the Hospital did not present evidence regarding the procedural issues. Caught off-guard by M.G.'s procedural error arguments, the Hospital's counsel requested clarification on the specific procedural issues. A lengthy colloquy then ensued between the parties and the ALJ. The ALJ reiterated his prior conclusion that the Hospital did not present evidence regarding the procedural issues, which "are affirmative obligations by . . . the Hospital." The ALJ told the Hospital that the procedural issues "are necessary to make a case for me to find that the patient needs to stay here. Anyone can testify to that effect, but I think you need to alert your witnesses that those items are necessary." Acknowledging that the law and medicine dictated conflicting outcomes, the ALJ explained:

I can't really have the Hospital reopen their case because [M.G.] didn't present a case. [She] just presented argument. [She] didn't present any evidence, so there's no evidence for the Hospital to rebut. So, legally, I must find that [M.G.'s counsel] is correct that the necessary procedures have not been shown to have been followed, and that [M.G.] is entitled to be discharged.

         The Hospital's counsel objected, arguing that "[M.G.] clearly is not in any condition to leave the hospital at this time[.]" The ALJ then determined that "[t]he only remedy that [he] could grant would be to allow the Hospital to reopen their case and present that evidence." The ALJ permitted the Hospital to continue its direct examination of Dr. Mirmirani on the limited issue of "how [M.G.] came to be admitted, " reasoning that:

[M.G.] raises a preliminary issue, the amount of time that she allegedly spent in the emergency room. It's not up to the Hospital to rebut that point during your case in chief. That's an affirmative defense, if you will, by which [M.G.] could move for release based on being outside the statutory limits in the emergency room. So, I don't fault the Hospital for not addressing that during their presentation.
As an administrative law judge, my function is basically to try to dispense low level justice and do the best for all the parties. I don't think it would be good for either the patient or the hospital to discharge her based on the possible technical deficiency and the hospital's evidence.
. . . I'll allow [the Hospital] to reopen [its] case if you want to recall Dr. Mirmirani on the issue of how [M.G.] came to be admitted here to this unit.
. . . I'll allow cross examination to include the issue of how [M.G.] came to the emergency room and how long she was there before she was transferred. I can only assume that those answers are in the medical records.

         The Hospital's counsel then recalled Dr. Mirmirani, who explained that the Hospital's emergency room differed from others in that it had a two-step process. The first step is triage and initial assessment by an emergency room physician in the main emergency room. The second step is a 23-hour stabilization unit where the patient is treated by a psychiatrist. In M.G.'s case, she was treated by both an emergency room physician and Dr. Ganjoo, a psychiatrist. Dr. Mirmirani was not able to testify to the length of M.G.'s stay in either the first or second step.

         Each party then presented closing arguments. M.G.'s counsel reiterated that the ALJ should grant M.G.'s release because of preadmission procedural errors-the length of stay and the notice of admission. After closing arguments, the ALJ denied M.G.'s motion for release, finding that procedural deficiencies were not "prejudicial to [M.G.]" and did not require her release. Addressing the primary violation-that [M.G.] was in the emergency room allegedly for 41 hours-the ALJ found:

Dr. Mirmirani testified about the uniqueness of this hospital's emergency room, having a 23-hour stabilization bed where [M.G.] apparently spent some time. That doesn't really circumvent the necessity of getting the patient out of the emergency room if she's going to be admitted to a psychiatric unit. But it does show that she -- even if she was in that unit for 41 hours, which is not really established by any evidence, she hasn't been prejudiced by it, nor has she been prejudiced by any possible failure to inform her of her admission status or her rights.
As I said, she is represented. She is here at the hearing. She has the same outlook as far as being released or retained as she would have if all those procedures were followed. I'm not sure that they weren't followed. So, I do not grant the motion for release based on any procedural errors. So, I find that any procedural errors, if there were any, are not of such magnitude as to require the patient's release.

(Emphasis added). Then the ALJ made express findings pertaining to each involuntary admission element enumerated in Health-Gen. ยง 10-632(e)(2)(i)-(v). First, the ALJ found that M.G. had "substance abuse psychosis with possible underlying schizophrenia." Second, the ALJ determined that M.G. required inpatient care and treatment. Third, the ALJ concluded that M.G. was a danger to herself because, among other reasons, an officer found her walking in traffic unaware of her surroundings. Fourth, he concluded that J.H. was unwilling and unable to be voluntarily admitted. Lastly, the ALJ determined that there was no available less restrictive form of ...

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