IN RE: L.K. (2026)

Forty-seven-year-old L.K. arrived at the Broadlawns Medical Center emergency department (ED) “highly agitated,” claiming that he was “being poisoned by others in his apartment.” L.K. complained that he was exposed to toxins coming through his vents which caused a “burning sensation” in his left eye. When the ED physician found no problem with his eyes, L.K. “became upset,” and the physician referred him for a psychiatric evaluation. After that evaluation, Broadlawns staff sought a mental health commitment, alleging L.K. was “seriously mentally impaired” as defined in Iowa Code section 229.1(22) (2025).

A magistrate found clear and convincing evidence of serious mental impairment and ordered L.K. committed for a complete psychiatric evaluation and appropriate treatment at Broadlawns. After a de novo trial, the district court reached the same finding. L.K. appeals, challenging the proof that, if he was allowed to remain at liberty, he was likely to inflict physical injury on himself or others. Because substantial evidence supports the district court's findings, we affirm.

I. Facts and Prior Proceedings

According to his sister, L.K. began to experience delusions at age forty. During his July 2025 ED visit, he spoke with Jennifer Melly, a psychiatric mental-health nurse practitioner. Melly observed that L.K. made “contradicting statements” that seemed delusional. For example, he claimed that he was a lawyer and had twenty cases waiting for him in court, that his father was the president of Liberia, and that he made a lot of money working at the United Nations and Salvation Army. But L.K.’s sister explained that his family helps pay his rent and other expenses.¹ Throughout his hospital stay, L.K. continued to complain to the nurses that he had “white specks” in his eyes.

Melly diagnosed L.K. with “unspecified psychosis rule out delusional disorder.” According to Melly, “Throughout this hospitalization, [he wasn't] one-hundred percent compliant with his medications” and exhibited “grandiosity pressured speech, [and] racing thoughts, [and] appear[ed] disorganized exhibiting tangential thoughts and flight of ideas and was difficult to redirect.” Melly also testified that L.K.’s judgmental capacity was “impaired to the point where [she] would question how he's able to meet his medical needs.”

The magistrate issued a hospitalization order on July 23, finding that due to mental illness, L.K. had poor insight regarding treatment. The order also found that L.K. “would benefit from treatment,” but without treatment L.K. was “likely to physically injure himself or others.”

L.K. appealed his commitment, contending he did not have poor judgmental capacity and that it was “false and misleading” to allege that he was “seriously mentally impaired.” The court held an evidentiary hearing on August 7, and Melly gave an updated report that L.K. still was not fully compliant with medications and continued to make delusional statements. In her opinion, L.K. still could not make responsible decisions and was likely to injure himself or others. After that hearing, the district court found clear and convincing proof that (1) L.K.’s judgment was “impaired by his mental illness,” (2) he was “treatable at present in an inpatient setting,” and (3) he was “a danger to himself and others.”

L.K. appeals, challenging the finding of “dangerousness.”

II. Scope and Standard of Review

We review L.K.’s challenge for the correction of legal error. See In re V.H., 996 N.W.2d 530, 536 (Iowa 2023). In evaluating his appellate claim, we are bound by the district court's factual findings when they are supported by substantial evidence. Id. “The allegations made in the application for involuntary commitment must be supported by clear and convincing evidence.” In re J.P., 574 N.W.2d 340, 342 (Iowa 1998). Under that standard, there must be “no serious or substantial doubt about the correctness of a particular conclusion drawn from the evidence.” Id. (citation omitted).

III. Analysis

Chapter 229 authorizes involuntary civil commitment if a person “has a serious mental impairment.” Iowa Code § 229.13(1). The statutory definition of “serious mental impairment” includes three elements. First, the person must have a mental illness. Id. § 229.1(22). But “[t]he existence of a mental illness, by itself, does not establish grounds for commitment.” J.P., 574 N.W.2d at 343. Second, because of the mental illness, the person must lack sufficient judgment to make responsible decisions related to hospitalization or medication. Iowa Code § 229.1(22). And third, because of their mental illness, the person must meet any of these grounds:

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.

Id. § 229.1(22)(a)–(d).

The third element is known as the “endangerment element” because proof of a serious mental impairment requires showing “a likelihood that the individual constitutes a danger to himself or others.” B.A.A. v. Chief Med. Officer, Univ. of Iowa Hosps. & Clinics, 421 N.W.2d 118, 123 (Iowa 1988) (examining dangerousness as prerequisite to involuntary commitment); see In re Mohr, 383 N.W.2d 539, 542 (Iowa 1986) (introducing the term “endangerment element”).

L.K. does not dispute the court's finding of mental illness or lack of judgment. He contests only the sufficiency of the proof of dangerousness.² He maintains that the State did not satisfy “its burden of demonstrating serious mental impairment, as evidenced by an overt act or threat.” To the contrary, L.K. maintains his interactions with people “although grandiose, and possibly delusional, were not violent or threatening.”

The district court found paragraphs (c) and (d) were the most applicable to L.K.’s situation. In assessing endangerment, the district court focused on L.K.’s inability to seek essential medical care and his lack of compliance with treatment:

[S]pecifically the Court finds that the evidence is that [L.K.] is unable to satisfy his need for essential medical care, and that it's likely he could suffer physical injury as a result of that. We also have (d), where there was testimony that he had a history of lack of compliance with treatment and that led him to the emergency room. Because of his mental illness, he thought he needed emergency care.

Substantial evidence supports the court's findings. The “endangerment element” requires evidence of a “recent overt act, attempt[,] or threat.” V.H., 996 N.W.2d at 543 (alteration in original) (citation omitted). Janus-like, that element “requires a predictive judgment, based on prior manifestations but nevertheless ultimately grounded on future rather than past danger.” Id. (citation omitted).

When asked about a recent overt act, nurse practitioner Melly testified that L.K. “continues to believe that there's these chemicals that are in his eyes. He's delusional, he's not taking his medication, and we would be risking decompensation.” The nurse practitioner explained that while L.K. was generally pleasant on the psychiatric unit, he was “very argumentative” when refusing to take his medication. She also described an event a day or two before the hearing when L.K. reported “severe anxiety.” L.K. “came out on the unit, and he took off his shirt, ․ exposing a scar on his chest where he believes the medications are causing him to have that scar.”

Our supreme court has found that a patient's similar agitated and confused state qualified as a recent overt act. See In re B.B., 826 N.W.2d 425, 433 (Iowa 2013). And our court has viewed an expressed refusal to take medication as a recent overt act. In re R.B., No. 23-1336, 2024 WL 1553808, at *3 (Iowa Ct. App. Apr. 10, 2024); In re C.B., No. 22-2089, 2023 WL 3092076, at *3 (Iowa Ct. App. Apr. 26, 2023).

Beyond L.K.’s resistance to medication, Melly remained “very concerned about the delusions and his food intake. He's made comments about ․ the kind of food he believes he should be eating.” She noted that L.K. was fixated on his apartment building: “[H]e has made so, so many calls, and he continues to present with delusions.” Melly also found no evidence to bolster L.K.’s belief that he was being harassed and feared that he could pose a danger to others by acting on those beliefs.

As the State argues, without committal, L.K. would be unlikely to comply with his medication regime and would spiral toward self-harm or harm to others should he act on his delusions of being under attack. And, as the district court found, he has previously needed emergency hospitalization due to his lack of compliance with treatment.

AFFIRMED.

FOOTNOTES

1.   Melly checked with the housing administrator at L.K.’s building, which did have regular spraying for pest control, but the administrator assured Melly that there were no concerns about hazardous chemicals in his apartment.

2.   In his appellant's brief, L.K. cites Iowa Code section 229.1(20), paragraphs (a)−(c), omitting paragraph (d), which was added eight years ago. See 2018 Iowa Acts ch. 1056, § 7. In July 2023, the definition of seriously mentally impaired was moved to section 229.1(22). See 2023 Iowa Acts ch. 19, § 515.

Opinion by Tabor, C.J.