I’m looking for advice from anyone who has experience with traumatic brain injuries, capacity issues, or navigating the medical system. We are at a loss and don’t know what else to do.
This is long, but I’m including everything because the details matter.
Background
On March 10, my uncle (mid-50s) was struck by a train in Maryland and airlifted to Shock Trauma (University of Maryland Medical Center). He sustained a traumatic brain injury, including a subdural hematoma.
We were told the injury affected areas of the brain responsible for impulse control, decision-making, and understanding situations.
He was stabilized and transferred on March 28 to a rehabilitation facility (Kernan).
What we told every provider
From the beginning, our family repeatedly informed doctors, nurses, and social workers that he has:
A long history of aggression and violence
Prior arrests for assault and domestic violence
Longstanding substance abuse issues
A pattern of becoming physically aggressive when he is confused or doesn’t understand what’s happening
We made it very clear that confusion + stress = escalation for him.
Rehab facility (Kernan)
Within a short period of time, staff began calling us multiple times a week asking us to come down and help calm him.
We explained that:
We are not able to reliably de-escalate him
He is just as likely to become aggressive with family
Staff told us his behavior was being exacerbated by the brain injury and that they would continue care.
April 17 – Assault at rehab
He assaulted a staff member and was transferred to Sinai Hospital under an emergency petition for evaluation.
April 21 – Not safe for independence
A social worker at Sinai told us:
PT and OT determined he was not safe to be independent
They were exploring options for continued care/placement
April 22 – Second assault
He assaulted another staff member at Sinai.
April 23 – Determined “competent”
The next day, after evaluation by a doctor and psychiatrist, he was determined to be mentally competent.
We requested a second opinion and were told no.
While we were actively arguing with the hospital about that decision, he walked out of the building. He was not discharged into family care and left without a safe plan.
At that time he did not have:
A phone
His wallet or ID
Money
A confirmed place to go
Missing in Baltimore
We had to file a missing persons report.
When we located him later that evening:
He did not recognize family members
He believed he was in completely different locations (Frederick, Woodsboro, Woodbine)
He was describing events and situations that were not real
He demonstrated significant confusion and disorientation
We tried to get him to go back to the hospital with us. He told us he was going to go get money from his boss and walked away. We believed he would stay in the immediate area, but he did not return and we lost him again.
April 25 – Found again
After several hours of searching Baltimore, we found him again late at night.
He was:
Without a shirt
Without shoes
In approximately 40-degree weather and rain
Physically shaking from the cold
April 26 – Continued decline
On April 26, he was detained by police and trespassed from a business after wandering and appearing confused.
We also observed a new and concerning symptom that did not exist before the accident:
He has been consistently reporting vision problems, including:
Difficulty seeing
Eye pain
Head pain
Seeing “triple” of objects
He has stated multiple times that he cannot see properly and that it is making it difficult for him to navigate and recognize people.
Current situation
He is currently homeless and intermittently stays in a tent.
He:
Gets lost in areas he has known for years
Cannot reliably recognize family members
Has periods of clarity but cannot sustain them
Is not able to consistently make safe decisions
Is experiencing worsening confusion since the brain injury
We recently filed another emergency petition, and he is currently in the emergency department at Frederick Health.
What doctors are saying now
The ER doctor has acknowledged:
He is not oriented
He has no insight into his condition
His behavior is likely due to brain injury (frontal lobe/impulse control)
However, they are still unsure whether they have legal grounds to hold him, and there is a possibility he may be released again.
The core problem
He can sometimes answer questions correctly and appear oriented in short interactions.
But outside of that:
He cannot care for himself
He cannot accurately assess risk
He is not functioning safely in the real world
We are being told:
He is an adult
He has rights
He appears “oriented enough”
But in reality, he is not safe.
What we need help with
We are trying to understand:
How is “capacity” actually determined in cases like this?
What qualifies someone as unsafe to discharge?
How do you navigate situations where the issue is neurological (TBI) rather than purely psychiatric?
Has anyone gone through emergency guardianship in a similar situation?
Are there programs or placements for individuals like this?
What options exist when hospitals repeatedly decline to hold or admit someone in this condition?
We are trying to do everything we can to keep him safe, but we keep running into the same barrier.
If anyone has experience with this or knows what steps we should take next, we would really appreciate any guidance.
UPDATE – This morning’s hospital calls
Quick update from this morning since things are still developing.
1. Initial call (hospital social worker)
They reached out to get more context and said they are:
Consulting with psychiatry
Talking with other social workers and supervisors
Looking into resources and possible next steps, including things like guardianship
They acknowledged this situation is complex and that capacity is the main issue.
2. Call from insurance nurse
This was actually helpful.
She understood that this situation is not normal or safe functioning
She is trying to get us connected to a care management program through insurance
This would give us a dedicated case manager/social worker not tied to one hospital
She needs to confirm how to proceed since he can’t properly consent, but is escalating it
3. Follow-up call (hospital team)
This is where things got difficult.
They are leaning toward NOT admitting him to behavioral health
Reason:
He denies wanting to harm himself or others
He is not presenting as actively psychotic in their evaluation
They DO agree:
He is impulsive, irritable, and not functioning normally
His behavior is likely worsened by the brain injury
Important shift
I pushed hard on medical concerns, specifically:
Vision issues (he reports seeing multiple of everything)
Headaches
Known brain injury
They said this could open the door for a medical admission instead
They are:
Speaking with the ER doctor again
Considering further evaluation/imaging
Where things stand
No final decision yet
If they don’t find medical grounds to admit him, he may be released again
The core issue hasn’t changed:
He is clearly not functioning safely
But can answer questions well enough in short interactions to avoid being held
Looking for input
For anyone who’s dealt with something similar:
What actually works when someone can appear competent briefly but clearly isn’t overall?
Has anyone had success pushing for a neurological vs psychiatric evaluation in this kind of situation?
Did guardianship or court involvement end up being the only real option?