Full Opinion

In The Court of Appeals Ninth District of Texas at Beaumont ________________ NO. 09-26-00019-CV ________________ IN THE INTEREST OF T.R.C. ________________________________________________________________________ On Appeal from the County Court at Law No. 3 Montgomery County, Texas Trial Cause No. 14-10-11718 ________________________________________________________________________ OPINION Mother appeals the trial court’s order terminating her parental rights to her minor child, T.R.C. (“Tim”).1 Termination of parental rights should be reserved for “extreme cases[.]” See In the Int. of H.S., No. 24-0307, 2026 Tex. App. LEXIS 533, at *2 (June 5, 2026). “[A] parental-termination order must always be a last resort and never a first impulse.” Id. We echo what was said by now Chief Justice Blacklock in In the Int. of A.M.: 1 To preserve the parties’ privacy, we use pseudonyms to refer to the child, Mother, foster parents, and family members. See Tex. Fam. Code Ann. § 109.002(d); Tex. R. App. P. 9.8(b)(2). 1 Most of the [appeals] this Court receives in parental-termination cases involve parents whose severe abuse or abandonment of their children, debilitating drug addiction, or violent and criminal behavior provide the clear and convincing evidence required for imposition of the draconian remedy of termination. This case is more difficult than most. It raises close questions of evidentiary sufficiency. 630 S.W.3d 25, 26 (Tex. 2019) (Blacklock, J.; concurring in the denial of the petition for review). We conclude the evidence is legally insufficient to support the trial court’s finding that the Department of Family and Protective Services (“the Department”) made reasonable efforts to return Tim to Mother before trial and that despite such efforts a continuing danger remains in the home that prevents Tim’s return to Mother. See Tex. Fam. Code Ann. § 161.001(f)(1). We, therefore, reverse the trial court’s order terminating Mother’s parental rights as to Tim, and render judgment that Mother’s rights are not terminated. We also conclude the trial court abused its discretion in ordering that the Department is Tim’s permanent managing conservator, because the trial court did not make the finding required by section 153.002(c)(1). See id. § 153.002(c)(1). Therefore, we reverse the trial court’s order appointing the Department as Tim’s permanent managing conservator. The Scope of Our Review vs. The Parameters of Our Opinion Although our legal sufficiency review requires us to conduct a thorough review of the entire record, our rules of procedure require us to “hand down a written opinion that is as brief as practicable but that addresses every issue raised and necessary to final disposition of the appeal.” Tex. R. App. P. 47.1 (emphasis added). 2 The distinction between what is reviewed and what is included in the opinion is particularly important in an appeal from a parental-termination order. “Appellate opinions in these important cases should distinguish between facts that support termination and facts that do not, rather than reciting every piece of evidence relied upon by the government.” In the Int. of A.M., 630 S.W.3d at 27 (Blacklock, J., concurring in the denial of the petition for review). We will attempt to heed Justice Massengale’s wise “caution against the dangers of kitchen-sink approaches to opinion writing, particularly in the area of parental-termination appeals.” In the Int. of A.K.T., No. 01-18-00647-CV, 2018 Tex. App. LEXIS 10018, at *47 (Tex. App.— Houston [1st Dist.] Dec. 6, 2018, pet. denied) (mem. op.) (Massengale, J., concurring); see also In the Int. of K.N., No. 24-0881, 2026 Tex. App. LEXIS 535, at *30 n.3 (June 5, 2026) (declining to recount evidence that “is not the basis of our judgment[,]” noting, “A kitchen-sink approach risks misleading lower courts as to what evidence matters.”). We will not, therefore, rehearse all the evidence the Department offered at trial and now argues on appeal as support for the trial court’s statutory-predicate and best-interest findings. As explained below, we do not reach those issues; instead, we decide this case by answering a separate question—whether the evidence is legally sufficient to establish, clearly and convincingly, that despite reasonable efforts by the Department to return Tim to Mother, a continuing danger remains in the home 3 that prevents his return. See Tex. Fam. Code Ann. § 161.001(f)(1). When deciding what evidence to include in our opinion, we have attempted to focus on the evidence that answers that question. Nevertheless, voluminous records were introduced at trial, and in order to comply with Rule 47.1, we must include sufficient details from those records to explain our disposition of this appeal. See Tex. R. App. P. 47.1 Factual Background When Tim was 17 months old, he was diagnosed with Type 1 diabetes, a serious condition which requires careful monitoring of Tim’s blood-sugar level. Too low a level can be immediately life-threatening; too high a level risks diabetic ketoacidosis which can potentially cause coma. Tim has a brother, “Chris,” who is one year younger than Tim. Mother has another son, “Trevor” who is several years older than Tim and Chris, and who was an adult at the time of trial. In 2016, when Tim was four and Chris was almost three, their parents divorced. The Final Decree of Divorce, signed in early 2017, appointed Mother as Tim’s and Chris’s sole managing conservator. Father, who was appointed possessory conservator, was to have periods of visitation, but these would be supervised by Tim’s grandmother or someone else approved by Mother, because the court found credible evidence Father engaged in a pattern of abuse and neglect directed at Mother and the children. Before any such visitation would be allowed, however, Father—and anyone else who would be supervising Tim during Father’s 4 periods of possession—would have to complete diabetes education training. No such requirement was placed on Mother who was granted the exclusive right to consent to the boys’ medical, dental, surgical, psychiatric and psychological treatment. 2 In September 2018, when Tim was six and Chris was five, Father died in a motorcycle accident. Years later, when the Department filed this action to terminate Mother’s parental rights in 2024, Tim and Chris were referred to Elizabeth Salmeron, Ph.D., for comprehensive psychological evaluations. The Department’s caseworker, Casandra Duran, informed Dr. Salmeron that Tim and Chris had been placed in separate homes, and that “the brothers do not have healthy boundaries . . . they fight often.” Dr. Salmeron did not testify, but her reports which were admitted into evidence indicate that both boys were dealing with multiple issues, including “grief and loss[.]” Tim expressed to Dr. Salmeron that he wished Father had “[n]ot crash[ed] on that day” and that his “dad could come back and the dogs and we all be together again as a family and the whole world not do bad things.” Based on information obtained from Tim’s paternal uncle, with whom Tim had been temporarily placed, Dr. Salmeron’s report indicates that Tim exhibited “the following problematic behaviors to a moderate to clinically significant degree:” feels sad; feels down on himself; worries a lot; fidgets or unable to sit still; distracts easily; 2 Father maintained the right to consent to non-invasive medical and dental treatment for the boys during Father’s periods of possession, and surgical treatment in the event of emergency. 5 has trouble concentrating; acts as if he were driven by a motor; fights with other children; does not listen to rules; does not understand other people’s feelings; teases others; refuses to share; takes things that do not belong to him; wants things right away; seems “hyperactive;” temper tantrums; and avoids talking about his feelings. Although Tim’s paternal uncle also reported that Tim “seems fearful of things that are reminders of the situation with his mom[,]” when Dr. Salmeron asked Tim the “one thing [he] want[ed] most in life[,]” Tim responded, “To be back with my mom.” Tim also told Dr. Salmeron, “I want to see my mom more often[,]” and when asked what he wished Mother would do differently, he replied, “I think she’s perfect.” As for what made Tim sad, he said, “My brother not being with my mom and me not being with my mom.” Although Tim was, at the time of his evaluation in January 2025, “currently functioning within the below average range in cognitive ability[,]” Dr. Salmeron’s report indicates his prognosis was “Fair[,]” and she recommended a “Specialized” level of care. Her report states: [Tim] has the necessary cognitive resources to build a productive problem-solving foundation; results suggest [Tim] has the potential to exercise positive stress tolerance and control choices. [Tim] comprehends the importance of cooperation; [Tim] is a good-natured child who benefits from validation, structure and routine. Uncle says [Tim] “is doing okay.” However, assessment information suggests Tim’s internal interpretation of his surroundings is influenced by stress; the impact of early significant loss and trauma also shapes how Tim is learning to “cope” with life. [Tim] has trouble imagining productive outcomes to events; test data show gaps in age level problem solving 6 skills sets. [Tim’s] private thoughts are marked by stress and tension, taking energy that could otherwise be channeled to build a stable coping structure. Given his age, [Tim] likely uses indirect ways of “signaling” needs for support, such as with anxiety-driven behaviors (“aggressive and dominates brother”; “argues with teacher”); the impact of early trauma may interrupt the healing process and leave [Tim] prone to inconsistent response to intervention over time. Test data suggest potential to internalize instead of express feelings; therefore, [Tim] is prone to denial, repression, minimization and avoidance over responsible assertiveness. The effects of uneven processing can exacerbate social problems as [Tim] may have trouble understanding and remembering what is expected of him in an organized fashion. Therefore, helping [Tim] develop productive communication and coping skills using trust-based discipline practices will be an important part of his treatment plan. We provide more details about the treatment plan recommended by Dr. Salmeron in our analysis below. But first, we believe it is necessary to include a description of events referenced in the medical records introduced during the trial, because the Department relies on those events in arguing that a continuing danger remains in the home because Mother is unable to manage Tim’s diabetes, unable to manage Tim’s behavior, and unfit to care for both Tim and Chris. Three exhibits containing over 12,700 pages of medical records pertaining to Tim were introduced during the trial, but only a handful of those records were ever discussed. The Department separately introduced six exhibits containing 33 pages excerpted out of the 12,700 pages and used those six exhibits to question Mother about the number of times she removed Tim from a hospital against medical advice. Only one other witness mentioned the medical records, citing them, globally, as the 7 basis for her concerns about Mother’s having removed Tim from hospitals against medical advice. Other witnesses expressed similar concerns without mentioning the records as the source of their knowledge, but none of the witnesses claimed to have any medical expertise other than a paramedic. The paramedic, readily conceding that lab values, metabolic status and treatment were “beyond [his] level of ability to testify[,]” provided limited testimony about diabetes in general and said that it was necessary for Tim to be transported to a hospital due to elevated blood-sugar on October 26, 2024. He never referred to, nor explained, any of the medical records. No doctor or nurse testified, either at trial or by way of deposition. In short, nobody provided any medical testimony explaining anything contained in the 12,700 pages of medical records introduced into evidence in the trial court and eventually forwarded to us as part of the appellate record. With that disclaimer, we provide the following information from the records, focusing mainly on the events described therein, touching on the medical information only as necessary to provide context for those events, and hopefully avoiding speculation on medical issues in the absence of medical testimony to explain the records.3 3 On appeal, the Department lists seven times Mother removed Tim against medical advice, and our review provides excerpts of the records regarding each, along with excerpts of other medical records containing relevant information. 8 December 5, 2018 When Tim was 6 years old, Mother called 911 and an ambulance transported Tim to the emergency department at Texas Children’s Hospital (“TCH”) The Woodlands due to “decreased PO intake [and] varying blood sugars (high and low)” one day after Tim had undergone tonsillectomy and adenoidectomy surgery. According to the records, Mother was “being demanding” and “interfering with patient care” while at TCH The Woodlands. “Per mother, she left AMA [against medical advice] because it took doctor so long to treat patient and were waiting on more blood work[.]” A social worker got involved and called Child Protective Services (“CPS”) because the medical staff was unsure whether Mother would take the child elsewhere for treatment. “Per mother, they left and went straight to Memorial Hermann ER. She is aware that CPS was called.” Memorial Hermann later reported to TCH West Tower (located in the Houston Medical Center) that Mother did, in fact, take Tim to Memorial Hermann, where blood work was done, Tim received fluids, and Memorial Hermann discharged him home. According to the records, Mother continued monitoring Tim’s blood sugar levels at home, and later that same day she called the endocrinology clinic which recommended that she take him to the emergency center, at which time she took him to TCH West Tower. The records reveal that while at TCH West Tower, Mother was “upset and yelling at healthcare staff at 0210 because PCA did not respond appropriately when she called. 9 Morning BG elevated at 292. Mother again upset and yelling this morning at 0800 because she reports that staff is not checking Tim’s BG levels often enough and is concerned that he is ketotic.” June 23, 2019 When Tim was 7 years old, Mother took Tim to the Kingwood Medical Center Emergency Department and reported that Tim had “passed a large ‘bright red blood clot’ during a BM today.” According to the records, Mother explained that Tim had been treated at TCH for abdominal pain, fever and gastrointestinal bleeding but was discharged two days prior with instructions to go to the emergency room if symptoms returned. 4 After waiting in the Kingwood emergency department for almost an hour, Mother left against medical advice. The records indicate the reason for leaving was: “Wait too long, Refused transfer, wants to drive pt to TCH. wait too long for transfer with EMS.” The records also indicate, “Doctor aware that mother does not want to wait for transfer to Texas Children’s Hospital downtown and would rather leave AMA at this time… Per doctor’s order at this time she would like for primary nurse to put in a CPS case/phone call.” The records indicate that thirty-four 4 The records from TCH confirm Tim had, in fact, been seen at TCH The Woodlands on June 20, 2019, for fever and bloody diarrhea and that Tim was discharged home on June 21, 2019, despite Mother’s statement that “she does not feel comfortable taking child home with continued diarrhea, fever, and elevated blood sugars.” 10 minutes later, Mother and Tim arrived at TCH The Woodlands’ emergency department where Tim was treated and later discharged. June 8, 2020 When Tim was 8 years old, someone identified as “step dad” dropped Tim off at TCH The Woodlands’s emergency department because Tim “was more tired than normal.” According to the records, “BS on arrival was 533, with Ketones 7.2.” Tim was diagnosed with diabetic ketoacidosis (DKA) and was admitted to the pediatric intensive care unit. Mother called and told the social worker that the night before, she took Tim to Taco Bell, watched him administer an insulin bolus, and then dropped him off at his paternal grandparents’ house so that Mother and her “entire family” could pack their things and move to another apartment since their current one had repeatedly been broken into. According to the records, “Mother stated she ‘hasn’t been able to stop crying’ since she found out patient was admitted[]” but she would not be able to come to the hospital until the next morning, stating that her ID was expired and that of her “husband” had been given to the police during their investigation of the break-in, and had not been returned. The records further indicate, [Social Worker] was involved due to initiate discharge planning along with CDE and clinical nutritionist as recommended. Mom was not at bedside to initiate discharge planning and education. Mom had reported to night shift that she would be here 06/09/2020 between 0600-0800 to bring home supplies. After numerous unsuccessful attempts to reach mom, [Social Worker] called for a wellness check. When PD arrived at house, mom stated she was sending a gentleman over to pick up the patient. PD initiated a CPS case at this time. The gentleman arrived with 11 no ID and was not allowed to pick up patient. As caregiver needed to be at bedside to receive discharge instruction, education and reinforcement regarding Type 1 DM management. Both mother and CPS arrived shortly after. Mother was visibly upset and frustrated. At this time, we tried consoling mother and letting her know that there still needs to be education to be provided and that with the sensitivity regarding the CPS case, [Tim] was not medically cleared for discharge. Mother continued to be uncooperative and at this time left against medical advice. CPS and [Social Worker] continues to be involved and will be following. …. CPS recommended not to release patient to mother initially, then agreed to let them go AMA[.] July 9, 2021 When Tim was 9 years old, Mother took Tim to the emergency center at TCH West Tower and stated that they had been “around town most of the day, and when they checked [Tim’s] glucose this evening for dinner it was 551.” She expressed concerns that Tim’s “Omnipod was malfunctioning” so she gave him an injection and some water, but he couldn’t drink much due to nausea and when she checked again it was “still elevated in the 400s,” so she gave him another injection. The records indicate that Tim’s nausea had “resolved” and his labs were “reassuring” as he did not meet the criteria for DKA, but “aggressive subcutaneous management” was recommended. The records indicate, After discussion with endocrine, recommendations made to mother including POC glucose, correction factor dosing, monitoring for additional 2 hrs. Mother became upset, threatened staff, stated that “we did not know about diabetes”, and that she needed to leave now. Mother 12 had already fed patient Whataburger, gave 2.5 units insulin. We attempted to help to facilitate more rapid additional treatment, reiterated recommendations, however mother refused additional interventions. [Patient] had already pulled out his IV. Mother refused to sign AMA paperwork however this remains AMA. Endocrine on call notified. …. Mother at nurses (sic) station and raised voice at nurses, EC MD brought to nurse’s station for update. Mother continued to escalate as she was escorted to room by two EC MD’s. Security called to bedside. After discussion with endocrine and EC medical staff, mother refused to stay for 2 hour observation per endocrine recommendations and mother reports patient removed the IV himself. Mother refused to sign AMA paperwork and left EC with security due to behavior. [Social Worker] notified. June 15, 2023 When Tim was 11 years old, Tim was transported by ambulance at the emergency center at TCH West Tower, arriving around 8:00 p.m. According to the records, Tim had threatened to harm his brother, and Mother was “concerned for suicidal ideation.” “No acute medical issues [were] identified.” Mental health services evaluated Tim, and inpatient psychiatric placement was recommended. Around 10:00 p.m., Tim was examined by Mary Hofstetter, MD, and was medically cleared. According to the nurse’s notes, around 11:00 p.m., Tim “escalat[ed] after sitter change… [Tim] called the sitter a ‘pedophille’ (sic) because sitter said she would need to accompany him to the bathroom for his safety. [Tim] was in the sitter’s face saying he had corona virus; sitter continued to ask [Tim] to sit back. 13 [Tim] said he would hit her as well.” Around that time, Mother “returned to bedside after getting coffee[,]” and a different sitter was assigned. By 3:08 p.m. the next day, Tim was still “[p]ending inpatient psychiatric placement[.] Medically cleared[,]” but one facility had “deferred admission” and another was listed only as a “potential” placement and was “still determining if able to perform insulin[.]” Around 6:00 p.m., twenty-two hours after admission, and with no placement confirmed, Mother “verbalized desire to leave with the patient.” Ashley Czaplicki, DO, was notified, and her 6:23 p.m. entry states: Called to bedside by nurse. Mother expressed frustration that placement is taking too long and she wishes to leave the hospital. She is frustrated with pt staying in same room for so long and is worried about insulin regimen. I explained that we are following endocrinology recommendations closely. Explained that placement is more difficult given underlying type I diabetes. Mother states that she does not want to wait any longer and would like to take him home. I explained that MHS and our team recommend inpatient treatment and are concerned that he could harm himself/others, disability, have worsening of his condition, and death. Mother expressed understanding and states that “has done this multiple times before. I don’t care if you call CPS. I’ve had CPS visit 10 times before.” Mother expressed understanding that she was leaving against medical advice. Advised return to ER for any worsening of condition such as increased aggression, voicing thoughts of harming self/others, fever, high blood glucose, or unable to eat/drink. Explained that she can return to ER at any time. Mother expressed understanding and agreement. July 8, 2024 This Court takes judicial notice that on July 8, 2024, Hurricane Beryl struck Montgomery County. Although it is unclear how Mother, Tim and Chris were 14 affected, medical records from November 2024 indicate, “Mother stated she filed for FEMA money from Hurricane Beryl in July 2024 and they have been staying at an extended stay hotel.” July 25, 2024 Tim woke up vomiting, and his blood glucose was 266, so Mother “called EMS for concerns for borderline DKA[,]” and Tim was transported to TCH The Woodlands. Tim, who was 12 years old at the time, was admitted to the PICU, and was seen by Bonnie McCann-Crosby, MD, for a Diabetes Consult on June 26, 2024. Her narrative states, [Tim] reports that he has been feeling bad for the past few days but he didn’t want to tell his mom because he doesn’t like going to the doctor… He is on Omnipod 5 insulin pump and the pump expired yesterday. He reports that he has been missing doses and sneaking food. He does not enter carb amounts in his pump. Mom feels that the Omnipod has not been working as well as his previous Tandem pump. She reports that the pump does not always connect with his Dexcom properly and he is often kicked out of auto mode and either in manual mode or limited mode. He is rotating his pump only on his arms. Doses immediately before eating if he pre-boluses. Reports that blood glucoses in general are in the 200s. …. Impression: Established DKA (DKA Resolved w/o ketones) [Tim] is a 12 y.o. [] male with type 1 diabetes, with poor glycemic control. He presented in critical condition with a clinical picture consistent of moderate diabetic ketoacidosis… and moderate dehydration. 15 …. Diabetes ketoacidosis is a hyperglycemic crises (sic) consistent with lack of insulin. It can result in several complications, including: hyperosmolality, dehydration, hypokalemia, hypophosphatemia, hypoglycemia, VTE, cerebral edema, coma and death. His presentation is suspected to be related to inadequate supervision, missed doses. Management recommendation is outlined below. We have discussed with the family that [Tim] was in serious condition, and diabetes acidosis carries significant risk of electrolyte abnormalities, cerebral edema and death. Ongoing parental supervision is critical to achieving good glycemic control in children and adolescents and preventing life-threatening complications of diabetes. Underlying cause for admission related to diabetes is thought to be due to missed insulin doses/inadequate supervision. Areas identified for improvement includes: supervising all doses, taking insulin for all carb meals and snacks, site rotation. [Tim] and his family will receive assessment by our multidisciplinary diabetes team during the admission to identify barriers of diabetes care, and ensure safe discharge and home care. …. Will switch to Lyumjev insulin upon discharge. Family does not want to continue OP5 upon discharge. They are to follow-up with primary endo about switching back to Tandem pump. …. Before being discharged by the hospital, Tim was also seen by Staci Grant, PsyD, for a Psychology Diagnostic Interview on June 26, 2024. Her narrative states, Mother provided information surrounding recent admission. [Tim] was reportedly admitted yesterday afternoon after he woke up and reported feeling weak. Mother called EMS for higher level of care and, due to 16 high blood glucose levels, he was taken to TCH ER. Mother reported that she believes this instance of DKA was due to possible “pod malfunction,” as she and [Tim] have had difficulty managing his glucometer and pump for the past few months. She noted that she believes he is experiencing diabetes burnout, given he has been more “forgetful” and “lazy,” and has been sneaking food at nighttime while playing video games. She shared that he was initially diagnosed at 17 months of age and has been admitted for DKA approximately 2 to 3 times. She recognizes that he appears more distressed currently and feels as if he needs to “push through.” As provider spoke with mother, [Tim] briefly mentioned he is “not burned out” and “does not want to do therapy.” Feels “interrogated” in meeting with several providers Previous Evaluation/Intervention: According to [Tim’s] caregiver, he has previously participated in evaluation and/or intervention including family therapy, individual therapy, and trauma services. Per mother, [Tim] has received multiple services throughout his lifetime and had difficulty recalling dates and names of providers. She noted that he was recently in foster care in 2022 and, as a result of physical abuse, he received trauma-informed care. Additionally, he participated in occupational therapy in 2023. Per mother’s report, she does not believe he has had a good experience with individual therapy, as he continually states that he “does not want to talk” and “feels forced” to participate. He has not received services to address diabetes management and care; however, mother believes a mentor and/or support groups would be more helpful. No official diagnoses Despite being evaluated on multiple occasions in the past, he has not received any official diagnoses and has been told to address prior trauma. …. Current Diagnosis: F43.20 Adjustment Disorder, Unspecified F90.2 Attention Deficit Hyperactivity Disorder, Combined (By history) 17 Recommendations/Plan: 1. Psychology follow-up is warranted and suggested at this time; however, patient refused. Mother was informed about possible reasons to request additional Psychology services should [Tim] be open to support in the near future. She is welcome to ask their provider or call Psychology directly… should they like another appointment. 2. Briefly discussed relationship between health and mood, highlighting impact of trauma and stressors on ability to participate effectively in management of health. 3. Encouraged mother to increase supervision of diabetes care daily and to schedule times for [Tim] to participate in gaming following participation in glucose checks and insulin administration. Referred to Psychiatry? no September 8, 2024 Tim woke up with a blood glucose level over 500. Tim was transported by EMS to the emergency department at TCH The Woodlands where Tim informed the staff that when he woke up, he found that his omnipod had expired. According to the records, Tim was examined by Nancy Shan, MD, who reported Tim was “not in DKA.” Nevertheless, Tim was admitted to the hospital with a nurse’s admission note that indicates, “Patient received from EC with diagnosis of DKA.” He was “accompanied by older brother [Trevor], [who] claims he is 20 yo and another sibling, 10 yo. [Trevor] claims he is the guardian, and signed consent and other documents at EC for admission[.]” The nurse’s notes indicate, Received an outside call…claims to be mother of patient. Told her Im (sic) am not able to give information since I have not met her and she does not have the code. She wanted to speak to the doctor ASAP 18 because she said did not give consent for her son to be admitted. She said her son is not in diabetes ketoacidosis, and that she can manage this at home. Claims that the patient’s pump just malfunctioned last night. Mother said that she wants her son discharged[.] Dr. Shan’s narrative indicates, [M]other not at bedside, older brother signed consent in ED to admit Patient. MD spoke to mother over phone with bedside RN present. Mother angry and belligerent on phone, stating that she did not want her child to be admitted as he is not in DKA and she can take care of his diabetes at home. Agreed with mother that yes, patient is not in DKA however his glucose and ketones were very elevated, and he required IVF and frequent insulin injections to prevent him from progressing into DKA. Updated mother that patient’s labs are improving but he has not yet met Endocrine criteria for discharge. Any premature leaving the hospital would be against medical advice. Mother stated that “Woodlands is stupid, they don’t know what they are doing, they are harming my child” and that she will sue the hospital. She also stated that if patient is not discharged home with older brother and she came to the hospital, it will be a “big deal”. Security aware of mother’s statements[.] The hospital’s Discharge Summary states, Mother arrived to bedside and refused to let RN given insulin for dinner carb coverage. [Social Worker] was notified and arrived outside patient room. As charge RN and MD were going to bedside, received notification from bedside RN that mother had removed patient’s PIV herself and left the hospital with him. MD had spoken to mother earlier on the phone and told mother that leaving the hospital before meeting Endocrine criteria for discharge would be against medical advise (sic). Patient arrived to hospital without insulin pump in place, and uncertain if/when new pump will be placed. He was not covered for his dinner carbs and he is in danger of worsening ketosis and hyperglycemia. Mother left with patient against medical advice. MD recommends CPS being called and patient brought back to ED for continued medical management. [Social Worker] aware. 19 October 9, 2024 Tim was transported by EMS to TCH The Woodlands for a “Behavioral Problem[.]” According to the emergency department’s records, Patient reports he gets angry sometimes. Reports he got mad at his brother today and “said some things he didn’t mean”, and got into a fight. Patient admits that he takes care of his diabetes, and monitors his blood sugar with the help of his mother. Mom reports family recently homeless, after moving out of a “questionable” hotel. Mom reports she was recently awarded her financial benefits from death of family member. Today family was at a motorcycle shop looking at dirt bikes, and having a mechanic look at younger siblings dirt bike for repair. Mom reports patient got upset, and started a fight with brother. In the midst of fighting patient was heard saying “I want to kill everyone, and then kill myself”. Patient has history of anger, and aggression. Mom reports she believes he would do it, do (sic) to his past history. Mom reports patient has had outside counseling, and psychiatry, however, due to their current financial situation, he has not been going. Patient unwilling to go into detail about what happened today, or how he feels, but denies current SI/HI, auditory or visual hallucinations. In no acute distress. Tim was admitted to the hospital and on October 10, 2024, a Diabetes Consult was conducted by Dr. McCann-Crosby, whose narrative indicates, He was noted to have hyperglycemia with ketosis in the EC. He is on an Omnipod pump but does not have a Dexcom currently and has been in manual mode. Per mom he has not been checking his blood sugars. He manages a lot of his diabetes on his own but does get some help from his mother. Mom reports that they are currently homeless. They were living in an extended stay, however mom was concerned about sex trafficking around the extended stay so they left and have been living in their car. Mom reports that she has 2 pit bulls and it has been difficult for her to find a place to rent that will accept the pit bulls… When asked about 20 the insulin storage, mom reports that it has not been kept consistently in a refrigerator recently…Yesterday [Tim] became upset and threatened to kill mom and his brother and then kill himself. Mom called EMS and they brought him to TCH The Woodlands. Mom was very upset this morning because she was initially told by the front desk on the 5th floor that they didn’t have record of [Tim] in the system. She reports that [Tim] has been listed under different names during several previous hospitalizations at TCH and she has had difficulty being able to see him during his admissions because “they can’t find him in the system”. She does not want to be admitted to TCH Woodlands in the future because of these concerns. Mom mentioned multiple times that she wants to take [Tim] and leave AMA. She reports that if CPS is called again she will not answer her phone if they call her. …. His presentation is to (sic) suspected to be related to missed insulin doses/inadequate supervision, likely bad insulin due to lack of refrigeration []. We have discussed with the family that Tim was in serious condition, and ketosis could result in acidosis/DKA and significant risk of electrolyte abnormalities, cerebral edema, and death. Ongoing parental supervision is critical to achieving good glycemic control in children and adolescents and preventing life-threatening complications of diabetes. Of note, the family is currently homeless and patient is not in school currently. [Social Worker] has met with the family and a new CPS case has been opened today. It is recommended that he be admitted to inpatient psych. He is medically cleared from an endocrine standpoint. Erlene Norris, LMSW, conducted a Social Work Psychological Assessment, which indicates, Per mother, she brought pt after he became agitated and got into a physical fight with his younger brother. According to mother, pt 21 became really upset and threatened to Kill himself and his mother and brother. Pt was previously diagnosed with ODD, ADHD and adjustment disorder. Per mother pt is not receiving treatment or taking any medication. Mother revealed the family is going through a crisis and are currently homeless. Mother also disclosed they have not been able to go to their endocrine appointments due to their crisis. Sw asked mother to tell her more about her crisis. Mother explained they were leaving (sic) at an apartment and had to leave that apartment and they left the medicines and everything behind. Mother disclosed they have been staying at ‘sketchy” hotels. …. [Social Worker] discussed with mother next steps including recommendation for inpatient treatment. Mother reporting she was in agreement as long as she could be at bedside. Mother identified Kingwood Pines as facility of choice. Four hours later, when an ambulance arrived to transport Tim to Kingwood Pines, Mother refused to sign the authorization. The nurse’s notes indicate Mother “[s]tated she will not allow for patient to be transferred to any hospital associated with TCH. Mother voiced frustration with our hospital contacting C