in the Interest of E. A. R., a Child ( 2019 )


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  •                                           COURT OF APPEALS
    EIGHTH DISTRICT OF TEXAS
    EL PASO, TEXAS
    §
    No. 08-19-00070-CV
    §
    IN THE INTEREST OF E.A.R.,                                                      Appeal from
    §
    A CHILD.                                                                    65th District Court
    §
    of El Paso County, Texas
    §
    (TC # 2017DCM5786)
    §
    OPINION
    M.J. appeals from an order terminating her parental rights to E.A.R. The trial court also
    terminated the parental rights of L.D.R. but he has not appealed. We affirm.
    FACTUAL SUMMARY
    M.J. and L.D.R. are the biological parents of E.A.R., who was twenty-one-months-old at
    the time of trial.1 On August 23, 2017 at approximately 1:00 p.m., Mary and Lyle took three-
    month-old Eddie to the emergency room at El Paso Children’s Hospital with a fever and
    congestion. According to Mary, Eddie had been congested for one week and she had been
    treating the fever with Tylenol, but the fever continued to spike. After observing bruising on the
    1
    To protect the identity of the child, the opinion will refer to M.J. by the fictitious name “Mary”, to L.D.R. by the
    fictitious name “Lyle”, and to E.A.R. by the fictitious name “Eddie”. See TEX.R.APP.P. 9.8.
    child’s face, torso, and back, the hospital staff made a report to the El Paso Police Department at
    3:28 p.m. on August 23.2 A police officer went to the hospital and began an investigation. A
    nurse at the hospital advised the officer that in addition to the bruising, they had discovered that
    the child had a torn frenulum which is typically caused by a bottle or some other object being
    forced into the child’s mouth. Photographs were made of the child’s injuries.
    Hospital staff also made a report to Child Protective Services on August 23, 2017 that
    Eddie had unexplained non-accidental injuries, including bruising and a torn frenulum.
    Kimberly Blair-Santaella, an investigator with the Texas Department of Family and Protective
    Services, went to the ER at Children’s Hospital to investigate. Blair-Santaella spoke with
    hospital personnel and learned that Eddie was undergoing additional testing including a full
    skeletal survey and testing to determine whether the child had any blood clotting abnormalities.
    Blair-Santaella examined Eddie and found cuts around his nose, bruising on his face, and
    numerous circular bruises on his stomach and the front of his torso. He also had bruises on his
    back. The bruises were different colors.
    Blair-Santaella spoke to Mary and Lyle about Eddie. Mary told her that she and Lyle
    were Eddie’s sole caregivers. Even though the bruises were readily visible to medical personnel
    and Blair-Santaella, Mary claimed to have not seen them. Mary explained that Eddie had been
    sick for three days and she had not changed his clothes or bathed him because she did not want
    to get him wet. Mary had changed Eddie’s diapers but did not see the bruises on his stomach.
    When asked to explain how the injuries might have occurred, Mary speculated that they could
    have been caused by the car seat or perhaps her siblings had played too rough with him when
    they had visited at the maternal grandmother’s house a week earlier. Mary did not express any
    concern about Eddie’s injuries. Eddie was admitted to the hospital. After speaking with the
    2
    The trial court took judicial notice of the police reports and medical records on file in the case.
    -2-
    maternal grandmother, Blair-Santaella created a safety plan which prohibited the child’s
    discharge from the hospital and restricted Mary and Lyle to supervised contact in the hospital.
    Blair-Santaella left the hospital. She returned to the hospital the following day and attempted to
    speak with Lyle about the bruising on Eddie. Lyle became extremely angry and said that the
    medical personnel in the emergency room had bruised Eddie. Mary agreed with Lyle and
    blamed the hospital personnel.
    Dr. Bert Emil Johannson, a pediatric intensivist and child abuse expert, consulted on the
    case to determine the cause of Eddie’s occult fever. A chest x-ray had revealed what medical
    personnel initially believed to be pneumonia in the upper left lobe of the lung. Dr. Johannson
    conducted a physical examination and noted that while Eddie was clean and well-fed, he had a
    pattern of bruising on the front and back of his thorax which suggested physical abuse in an
    immobile three-month-old child.      He also observed that the bruises were different colors
    indicating that they had occurred over a period of days. Eddie was also tender over his anterior
    ribs and posterior left-side ribs. Consequently, they ordered a skeletal survey which revealed
    that Eddie had multiple fractured ribs and a fractured arm. In light of those results, the doctors
    ordered a chest CT. That examination showed the presence of hematomas beneath the fractured
    ribs and those hematomas had become infected. Eddie eventually had to undergo surgery to
    drain an abscess that was causing the infection. Dr. Johannson also testified that Eddie had a
    torn frenulum midline beneath the tongue. He explained that the frenulum is “very difficult to
    tear” and he described Eddie’s injury as a forcible tear. Dr. Johannson testified that a torn
    frenulum can be caused by someone pulling on the child’s tongue or forcing an object in the
    child’s mouth. Through testing, Dr. Johannson ruled out any diseases which might have caused
    the fracturing and bruising seen in Eddie.
    -3-
    In Dr. Johannson’s opinion, Eddie’s injuries were “absolutely caused by abuse of this
    child.” He testified that it would have taken the force equivalent to a 25-pound bowling ball
    dropped from the distance of one meter to break a rib. In his opinion, an even greater amount of
    force was applied here because the broken ribs were tilted downward. Dr. Johannson concluded
    that the broken ribs were likely caused by a punch. He noted that the parents had not offered any
    plausible explanation for Eddie’s fractures.
    After receiving a call from Dr. Johannson, Blair-Santaella returned to the hospital to
    speak with Mary and Lyle about the rib and arm fractures. According to Blair-Santaella, the
    skeletal survey showed that the arm fracture was older than the rib fractures. Both parents
    denied any knowledge of the injuries or how they occurred. Mary did not say much in response
    to the news, but Lyle became angry and continued to insist that the Department should be
    investigating the hospital staff rather than them. On August 29, Blair-Santaella notified the
    parents that the Department was going to remove Eddie. The Department filed a petition for
    conservatorship and termination that same day. Eddie remained in the hospital until September
    11, 2017, and he was placed in foster care.
    The Department created service plans for both parents and engaged in efforts to reunify
    the family. After observing behavioral changes in both Mary and Lyle, the Department created a
    transition plan and both parents agreed to it. A few weeks later, however, the Department
    received an intake alleging physical abuse and neglect because Eddie had a diaper rash and
    bruises. After an investigation, the Department ruled out physical neglect, but it was unable to
    make a determination on all parties with respect to the physical abuse. The transition plan was
    put on hold and the parents went back to supervised visits.
    The supervised visits went well and the Department developed a transition plan. Mary
    -4-
    and Lyle had overnight visits with Eddie from August 15-18. On August 19, the Department
    received an intake that Lyle had burned Mary’s nine-year-old brother, V.J. Detective Paul Mata,
    who is assigned to the Crimes Against Children Unit of the El Paso Police Department,
    investigated the injury to a child offense which was alleged to have occurred on August 13,
    2018, and conducted the forensic interview of V.J. V.J. accused Lyle of intentionally burning
    him with a hot fork. V.J. explained that he was cooking a weenie on a fork over the flame on the
    stove. Both Mary and Lyle were present. V.J. left the weenie cooking over the flame and Mary
    took it off of the stovetop but burned herself with the hot fork. Mary began crying and Lyle
    asked her what had happened. Mary explained that the hot fork had burned her and she gave the
    weenie and fork to Lyle. When V.J. extended his hand and arm to reach for the weenie, Lyle
    intentionally pressed the hot fork against V.J.’s shoulder and burned him. V.J. screamed in pain.
    Upon learning of the incident a few days later, V.J.’s father3 reported the offense to the police on
    August 18. Lyle attempted to convince V.J. to say that the burn injury was an accident, but V.J.
    continued to state it was intentional. Detective Mata repeatedly attempted to speak with Mary
    and Lyle about the incident, but neither of them returned his calls. In October 2018, Detective
    Mata obtained a warrant for Lyle’s arrest, but the warrant had not yet been executed when the
    detective testified in this case in February 2019.
    The Department conducted its own investigation of the incident involving V.J. Lyle told
    the Department’s investigator that it was an accident. Because the injury was consistent with the
    child’s statement that Lyle had intentionally held the hot fork against his skin, the Department
    found V.J. credible and found reason to believe that Lyle had injured the child. On August 22,
    2018, Mary contacted Illiana Ladd, a conservatorship caseworker with the Department, to
    discuss the incident involving V.J. Mary claimed that the injury to V.J. was an accident and V.J.
    3
    V.J.’s father and mother are separated.
    -5-
    had been manipulated by her father to say it was intentional. At trial several months later, she
    testified that V.J. told her that he did not know whether Lyle had burned him intentionally. Mary
    admitted that she could clearly see the prongs of the fork in photographs of V.J.’s burn injury.
    Because Mary insisted that Lyle did not intentionally burn V.J., Ladd became concerned about
    Mary’s ability to protect Eddie.
    Cynthia Leede provided professional counseling services to Mary and Lyle. The purpose
    of her counseling was to assist both Mary and Lyle with improving their parenting skills and
    their relationship with one another and the child. She was also required to provide anger
    management counseling for Lyle, but that never occurred because both Mary and Lyle stopped
    attended counseling. Mary reported having racing thoughts and presented with anxiety and
    symptoms of depressed mood. Mary attended only two counseling sessions because she did not
    have transportation.   During those sessions, Mary did not take personal responsibility or
    accountability for what happened to Eddie. She instead blamed the hospital staff for Eddie’s
    injuries, or alternatively, she speculated that her siblings might have caused the injuries. Leede
    explained that part of the therapeutic process is taking accountability for your own actions
    whether it is for causing the injuries or leaving the child with someone else who caused the
    injuries. Thus, she expected the parents to show some degree of accountability, but neither did.
    Leede questioned Mary’s ability to parent and protect the child based on the lack of
    accountability and the inability to address her own medical needs.
    When the Department began the first transition plan, it recommended that Mary and Lyle
    obtain additional counseling because Mary was feeding Eddie items that caused him to have
    diarrhea. Eddie is lactose intolerant. Additionally, Eddie repeatedly contracted head lice during
    his parent-child visits, but Mary and Lyle denied the problem and refused to address it.
    -6-
    The evidence also showed that Mary and Lyle did not have stable housing during the
    pendency of the case. Mary and Lyle lived with grandmother following Eddie’s birth, but they
    had to leave the home after the injury to V.J. Mary and Lyle subsequently lived with a friend
    from church, but the caseworker, Illiana Ladd, was unable to visit the home because she could
    not get an exact address from Mary and Lyle. After leaving that home, Mary and Lyle lived with
    another friend for one month and then with Mary’s cousin for two weeks. Mary and Lyle
    purportedly rented a house from October 2018 to January 2019, but Ladd attempted to make five
    home visits and was never able to confirm that they lived there. At the time of the termination
    hearing, Mary and Lyle had separated and Mary was living with her mother who lives in
    government housing. Five children, including V.J., live in the home. Mary’s mother has stage
    IV cancer and will require long-term care.
    The Department decided to not move forward with reunification because Mary and Lyle:
    (1) never had a plausible explanation for Eddie’s injuries even though they were the sole
    caregivers; (2) insisted that V.J.’s burn injury was accidental; (3) lacked the capacity to protect
    the child; and (4) they did not have home stability. The trial court found that the Department had
    proven by clear and convincing evidence that Mary had (1) knowingly placed or knowingly
    allowed the child to remain in conditions or surroundings which endanger the physical or
    emotional well-being of the child, pursuant to § 161.00l(b)(l)(D), Texas Family Code, and (2)
    engaged in conduct or knowingly placed the child with persons who engaged in conduct which
    endangered the physical or emotional well-being of the child, pursuant to § 161.001(b)(1)(E),
    Texas Family Code. The court also found by clear and convincing evidence that termination of
    Mary’s parental rights was in the child’s best interest, and it appointed the Department as the
    child’s permanent managing conservator.
    -7-
    PREDICATE TERMINATION GROUNDS
    In Issues One and Two, Mary challenges the legal and factual sufficiency of the evidence
    supporting the trial court’s endangerment findings under Section 161.001(b)(1)(D) and (E). See
    TEX.FAM.CODE ANN. § 161.001(b)(1)(D), (E). Parental rights may be involuntarily terminated
    through proceedings brought under Section 161.001 of the Texas Family Code.                      See
    TEX.FAM.CODE ANN. § 161.001. Under this provision, the petitioner must (1) establish one or
    more of the statutory acts or omissions enumerated as grounds for termination, and (2) prove that
    termination is in the best interest of the children. See 
    id. Both elements
    must be established, and
    termination may not be based solely on the best interest of the child as determined by the trier of
    fact. Texas Department of Human Services v. Boyd, 
    727 S.W.2d 531
    , 533 (Tex. 1987); In the
    Interest of A.B.B., 
    482 S.W.3d 135
    , 138 (Tex.App.--El Paso 2015, pet. dism’d w.o.j.). Only one
    predicate finding under Section 161.001(b)(1) is necessary to support a judgment of termination
    when there is also a finding that termination is in the child’s best interest. In re A.V., 
    113 S.W.3d 355
    , 362 (Tex. 2003). However, when a parent’s rights have been terminated based on multiple
    grounds, including subsections D or E, we must address any sufficiency challenges directed at
    subsections D and/or E, even if the evidence is sufficient to support termination on other
    predicate grounds. In re Z.M.M., No. 18-0734, --- S.W.3d ---, 
    2019 WL 2147266
    , at *2 (Tex.
    May 17, 2019) (per curiam); see In re N.G., No. 18-0508, --- S.W.3d ---, 
    2019 WL 2147263
    at
    *3 (Tex. May 17, 2019)(holding that due process and due course of law require an appellate
    court to review and detail its analysis as to termination of parental rights under subsections D or
    E). We will affirm the termination order if the evidence is both legally and factually sufficient to
    support any alleged statutory ground the trial court relied upon in terminating the parental rights
    -8-
    as well as the finding of best interest. J.S. v. Texas Department of Family and Protective
    Services, 
    511 S.W.3d 145
    , 159 (Tex.App.--El Paso 2014, no pet.).
    Standards of Review
    When reviewing the legal sufficiency of the evidence in a termination case, we consider
    all of the evidence in the light most favorable to the trial court’s finding, “to determine whether a
    reasonable trier of fact could have formed a firm belief or conviction that its finding was true.”
    In the Interest of J.P.B., 
    180 S.W.3d 570
    , 573 (Tex. 2005), quoting In re J.F.C., 
    96 S.W.3d 256
    ,
    266 (Tex. 2002); see In re J.O.A., 
    283 S.W.3d 336
    , 344 (Tex. 2009). We give deference to the
    fact finder’s conclusions, indulge every reasonable inference from the evidence in favor of that
    finding, and presume the fact finder resolved any disputed facts in favor of its findings, so long
    as a reasonable fact finder could do so. In the Interest of 
    J.P.B., 180 S.W.3d at 573
    . We
    disregard any evidence that a reasonable fact finder could have disbelieved, or found to have
    been incredible, but we do not disregard undisputed facts. In re 
    J.P.B., 180 S.W.3d at 573
    ; In re
    
    J.F.C., 96 S.W.3d at 266
    .
    In a factual sufficiency review, the inquiry is whether the evidence is such that a fact
    finder could reasonably form a firm belief or conviction about the challenge findings. See In re
    
    J.F.C., 96 S.W.3d at 266
    . We must give due consideration to evidence that the fact finder could
    reasonably have found to be clear and convincing. In re 
    J.F.C., 96 S.W.3d at 266
    . A court of
    appeals should consider whether disputed evidence is such that a reasonable fact finder could not
    have resolved that disputed evidence in favor of its finding. 
    Id. If the
    disputed evidence that a
    reasonable fact finder could not have credited in favor of the finding is so significant that a fact
    finder could not reasonably have formed a firm belief or conviction, then the evidence is
    factually insufficient. 
    Id. -9- Endangerment
    A parent’s rights may be terminated if there is clear and convincing evidence that the
    parent has knowingly placed or knowingly allowed the child to remain in conditions or
    surroundings which endanger the physical or emotional well-being of the child.                   See
    TEX.FAM.CODE ANN. § 161.001(b)(1)(D).            Under subsection E, a parent’s rights may be
    terminated if there is clear and convincing evidence that the parent engaged in conduct or
    knowingly placed the child with persons who engaged in conduct which endanger the physical or
    emotional well-being of the child. See TEX.FAM.CODE ANN. § 161.001(b)(1)(E). In the context
    of subsections D and E, the term “endanger” means to expose to loss or injury, or to jeopardize a
    child’s emotional or physical health. In re M.C., 
    917 S.W.2d 268
    , 269 (Tex. 1996); A.S. v. Texas
    Department of Family and Protective Services, 
    394 S.W.3d 703
    , 711 (Tex.App.--El Paso 2012,
    no pet.). Even though much of the evidence admitted at trial is relevant to both subsections, we
    will conduct a separate analysis for each.
    Section 161.001(b)(1)(D)
    Subsection D requires a showing that the environment in which the child is placed
    endangered the child’s physical or emotional health. Doyle v. Texas Department of Protective
    and Regulatory Services, 
    16 S.W.3d 390
    , 394 (Tex.App.--El Paso 2000, pet. denied). The
    child’s environment refers to the suitability of the child’s living conditions as well as the conduct
    of parents or others in the home. In re S.R., 
    452 S.W.3d 351
    , 360 (Tex.App.--Houston [14th
    Dist.] 2014, pet. denied). A child is endangered when the environment creates a potential for
    danger that the parent is aware of but disregards. In re E.R.W., 
    528 S.W.3d 251
    , 264 (Tex.App.--
    Houston [14th Dist.] 2017, no pet.). The relevant time frame to determine whether there is clear
    and convincing evidence of endangerment is before the child was removed. Ybarra v. Texas
    - 10 -
    Department of Human Services, 
    869 S.W.2d 574
    , 577 (Tex.App.--Corpus Christi 1993, no pet.).
    When seeking termination under subsection D, the Department must show that the child’s living
    conditions pose a real threat of injury or harm. In re 
    N.R., 101 S.W.3d at 776
    ; 
    Ybarra, 869 S.W.2d at 577
    .      Conduct that demonstrates awareness of an endangering environment is
    sufficient to show endangerment. In re S.M.L., 
    171 S.W.3d 472
    , 477 (Tex.App.--Houston [14th
    Dist.] 2005, no pet.).
    Mary argues that the Department introduced no evidence of Eddie’s living environment
    with Mary or Lyle before August 23, 2017.              In the context of subsection D, the term
    “environment” includes the conduct of the parents or others in in the home. See In re 
    S.R., 452 S.W.3d at 360
    ; In re W.S., 
    899 S.W.2d 772
    , 776 (Tex.App.--Fort Worth 1995, no writ).
    Inappropriate, abusive, or unlawful conduct by persons who live in the child’s home or with
    whom the child is compelled to associate on a regular basis in his home is a part of the
    “conditions or surroundings” of the child’s home under section 161.001(1)(D). In re M.R.J.M.,
    
    280 S.W.3d 494
    , 502 (Tex.App.--Fort Worth 2009, no pet.). Further, a child’s unexplained, non-
    accidental fractures of various ages support a reasonable inference that the child’s caregivers
    knew of the injuries and their cause, and supports termination under subsection D. In re L.M.M.,
    
    522 S.W.3d 34
    , 45 (Tex.App.--Houston [1st Dist.] 2017, pet. denied); In re J.D., 
    436 S.W.3d 105
    , 114 (Tex.App.--Houston [14th Dist.] 2014, no pet.).
    Three-month-old Eddie was taken to the ER on August 23, 2017 with a fever and
    congestion. Hospital personnel observed that Eddie had non-accidental injuries, including a torn
    frenulum and bruising on his stomach and torso.             Consequently, additional testing was
    performed. It was determined over the next couple of days that Eddie had suffered serious
    injuries, including fractured ribs and a fractured arm. Through testing, the doctors ruled out any
    - 11 -
    diseases which might have caused the fracturing and bruising seen in Eddie.
    The expert witness, Dr. Johannson, testified that Eddie’s injuries were “absolutely” the
    result of child abuse, and he concluded that the broken ribs were caused by a punch. According
    to Dr. Johannson, the force required to break the child’s ribs exceeded that of a 25-pound
    bowling ball dropped from a distance of one meter. Dr. Johannson testified that the rib fractures
    occurred on a single day, but the bruising on Eddie’s torso also occurred over a period of days.
    There is also evidence that the arm fracture was an older injury than the rib injuries. Mary and
    Lyle were Eddie’s sole caregivers yet neither of them had any plausible explanation for the
    injuries. The presence of these unexplained, non-accidental fractures of various ages supports a
    reasonable inference that Mary and Lyle knew of the injuries and their cause, and supports
    termination under subsection D. See In re L.M 
    M., 522 S.W.3d at 45
    ; In re 
    J.D., 436 S.W.3d at 114
    . We conclude that the evidence, viewed in the light most favorable to the challenged
    finding, was sufficient for a reasonable factfinder to have formed a firm belief or conviction that
    Mary knowingly allowed Eddie to remain in conditions or surroundings which endangered his
    physical well-being. See In re L.M.
    M., 522 S.W.3d at 45
    (evidence sufficient to support finding
    of endangerment under subsection D where mother was primary caregiver, child had
    unexplained injuries including multiple brain hemorrhages of varying ages and more than twenty
    broken bones of varying ages, and medical records characterize the injuries as likely related to
    non-accidental trauma and consistent with child abuse); In re J.D.B., 
    435 S.W.3d 452
    , 464-66
    (Tex.App.--Dallas 2014, no pet.)(evidence sufficient to support finding that parents knowingly
    placed or allowed one-year-old child to remain in conditions or surroundings that endangered his
    physical or emotional well-being where multiple physicians found no explanation for fractures
    apart from intentional infliction, new fractures stopped appearing when child was removed from
    - 12 -
    parents’ custody, and parents’ expert offered no explanation for torn frenulum and deep scratches
    on child’s face).
    In examining the factual sufficiency of the evidence supporting the finding under
    subsection D, we have considered whether the disputed evidence is such that a reasonable fact
    finder could not have resolved the evidence in favor of its finding. In re 
    J.F.C., 96 S.W.3d at 266
    . Both Mary and Lyle repeatedly insisted that they did not know how Eddie had sustained
    the injuries. Alternatively, they asserted that the hospital staff caused the bruises after Eddie
    arrived at the hospital. At trial, Mary denied that she or Lyle caused any of Eddie’s injuries.
    Mary testified that she had never seen Lyle be violent with Eddie, strike, shake, or throw Eddie,
    or pull his tongue. She admitted that Lyle was alone with Eddie in mid-July 2017 when she was
    in summer school. Mary testified that she did not know whether Lyle did anything to Eddie
    when she was not present. She also did not recall whether she asked Lyle if he had caused the
    injuries. It was within the province of the trial judge, as the trier of fact, to evaluate the
    demeanor and credibility of all the witnesses, including Mary, and to weigh the evidence. 
    J.B.P., 180 S.W.3d at 574
    . The trial court could have reasonably concluded that Mary’s denial of any
    knowledge of Eddie’s injuries or how they occurred lacked credibility given the nature of the
    injuries, including the visible bruising on his stomach and torso. Mary’s assertion that the
    hospital staff caused the bruising is inconsistent with the evidence showing that medical
    personnel discovered the bruising shortly after Eddie arrived at the ER. The hospital staff
    quickly reported the non-accidental injuries to both the police and the Department. Further, the
    evidence showed that the bruising had occurred over a period of days. Mary presented no
    explanation for Eddie’s fractured bones or the torn frenulum. Despite the severity of the injuries,
    Mary also claimed that Eddie was a “very calm baby” and never cried in a manner indicating he
    - 13 -
    had been hurt or injured while in her care. She said that after Eddie had been admitted to the
    hospital for three days, she noticed that he would cry when they wrapped him but he never cried
    before that. After considering all of the evidence, including Mary’s claim that she was not aware
    of any of Eddie’s injuries, we conclude that a reasonable factfinder could have reconciled the
    disputed evidence in favor of the trial court’s endangerment finding, and the trial court could
    have reasonably formed a firm conviction or belief that Mary knowingly allowed Eddie to
    remain in an endangering environment. See In re L.M.
    M., 522 S.W.3d at 45
    . Accordingly, we
    hold that the evidence was legally and factually sufficient to support the subsection D
    endangerment finding. Issue One is overruled.
    Section 161.001(b)(1)(E)
    In Issue Two, Mary attacks the legal and factual sufficiency of the evidence supporting
    the trial court’s finding that she engaged in conduct or knowingly placed the child with persons
    who engaged in conduct which endangered the physical or emotional well-being of the child.
    See TEX.FAM.CODE ANN. § 161.001(b)(1)(E).              The term “conduct,” as used in Section
    161.001(b)(1)(E), includes both the parent’s actions and failures to act. In re M.J.M.L., 
    31 S.W.3d 347
    , 351 (Tex.App.--San Antonio 2000, pet. denied). Conduct that subjects a child to a
    life of uncertainty and instability endangers the physical and emotional well-being of a child.
    See A.S. v. Texas Department of Family and Protective Services, 
    394 S.W.3d 703
    , 712
    (Tex.App.--El Paso 2012, no pet.); In re 
    M.R.J.M., 280 S.W.3d at 503
    .
    Under Section 161.001(b)(1)(E), the relevant inquiry is whether evidence exists that the
    endangerment of the child’s physical and emotional well-being was the direct result of the
    parent’s conduct, including acts, omissions, or failures to act. See In re J.T.G., 
    121 S.W.3d 117
    ,
    125 (Tex.App.--Fort Worth 2003, no pet.). Termination under this subsection must be based on
    - 14 -
    more than a single act or omission; the statute requires a voluntary, deliberate, and conscious
    course of conduct by the parent. 
    Id. When determining
    whether a parent has engaged in an
    endangering course of conduct, a fact finder may consider the parent’s actions and inactions that
    occurred both before and after the child was born. See In re J.O.A., 
    283 S.W.3d 336
    , 345 (Tex.
    2009); In re B.C.S., 
    479 S.W.3d 918
    , 926 (Tex.App.--El Paso 2015, no pet.); In re S.M., 
    389 S.W.3d 483
    , 491-92 (Tex.App.--El Paso 2012, no pet.). The conduct need not occur in the
    child’s presence, and it may occur both before and after the child has been removed by the
    Department. Walker v. Texas Department of Family & Protective Services, 
    312 S.W.3d 608
    , 617
    (Tex.App.--Houston [1st Dist.] 2009, pet. denied). Scienter is not required for an appellant’s
    own acts under Section 161.001(b)(1)(E), although it is required when a parent places her child
    with others who engage in endangering acts. In re U.P., 
    105 S.W.3d 222
    , 236 (Tex.App.--
    Houston [14th Dist.] 2003, pet. denied).
    The child sustained multiple fractured ribs, a broken arm, extensive bruising of his
    stomach and torso, and a torn frenulum while in the care of Mary and Lyle. The injuries
    occurred over a period of time and were not accidental. To the contrary, Dr. Johannson testified
    that the injuries were “absolutely” the result of child abuse. Even though some of the injuries
    were caused by significant force, Mary claimed to not have any idea that the child was injured at
    all or how the injuries occurred. While she stated that Eddie bruised easily and her younger
    siblings might have unintentionally bruised Eddie, medical testing ruled out the possibility of any
    blood-clotting disorders. Further, Mary had no explanation for the fractured bones and torn
    frenulum. The counselor, Ms. Leede, observed that Mary was protective of Lyle and did not say
    anything negative about him. Mary continued to be protective of Lyle throughout the pendency
    of the case even though her parental rights were at risk. In August 2018, Mary’s younger
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    brother, V.J., reported that Lyle intentionally burned him with a hot fork. Mary approached the
    conservatorship caseworker a few days later stating that the injury to V.J. was accidental and
    V.J. had been manipulated by his father to state the injury was intentional.                After an
    investigation, the Department concluded that the evidence, including photographs of the burn
    injury, was consistent with V.J.’s statement that Lyle intentionally burned him. At trial, Mary
    insisted that her back was turned when the injury occurred and V.J. told her that he did not know
    whether Lyle had intentionally burned him.
    We conclude that the evidence, viewed in the light most favorable to the challenged
    finding, was sufficient for a reasonable factfinder to have formed a firm belief or conviction that
    Mary engaged in conduct or knowingly placed the child with persons who engaged in conduct
    which endangered the physical or emotional well-being of the child. See In re J.D., 
    436 S.W.3d 105
    , 115-16 (Tex.App.--Houston [14th Dist.] 2014, no pet.)(finding evidence legally and
    factually sufficient under subsections D and E where the child sustained two fractures at different
    times while in the parent’s care, the injuries were not accidental, but were caused by extreme
    force, bone disease was ruled out, and the parent was the primary caretaker).
    In examining the factual sufficiency of the evidence supporting the finding under
    subsection E, we have considered whether the disputed evidence is such that a reasonable fact
    finder could not have resolved the evidence in favor of its finding. In re 
    J.F.C., 96 S.W.3d at 266
    . As detailed in our analysis of the sufficiency arguments related to subsection D, both Mary
    and Lyle maintained that they did not know how Eddie had sustained the injuries. Their
    explanation that the hospital staff caused the bruises after Eddie arrived at the hospital is contrary
    to the evidence showing that the bruises were visible when Eddie was examined in the ER on the
    afternoon of August 23, 2017. Mary testified that she had never seen Lyle be violent with Eddie
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    or do anything which might have caused the injuries. Mary presented no explanation for Eddie’s
    fractured bones or the torn frenulum. The trial court could have reasonably concluded that
    Mary’s denial of any knowledge of Eddie’s injuries or how they occurred lacked credibility
    given the nature of the injuries, including the visible bruising on his stomach and torso. After
    considering all of the evidence, we conclude that a reasonable factfinder could have reconciled
    the disputed evidence in favor of the trial court’s endangerment finding, and the trial court could
    have reasonably formed a firm conviction or belief that Mary engaged in conduct or knowingly
    placed the child with persons who engaged in conduct which endangered the physical or
    emotional well-being of the child. See In re 
    J.D., 436 S.W.3d at 115-16
    . Accordingly, we hold
    that the evidence was legally and factually sufficient to support the subsection E endangerment
    finding. Issue Two is overruled.
    BEST INTEREST
    In Issue Three, Mary argues that the evidence is legally and factually insufficient to
    support the best interest finding made under Section 161.001(b)(2) of the Family Code. A
    determination of best interest necessitates a focus on the child, not the parent. See In the Interest
    of B.C.S., 
    479 S.W.3d 918
    , 927 (Tex.App.--El Paso 2015, no pet.); In the Interest of R.F., 
    115 S.W.3d 804
    , 812 (Tex.App.--Dallas 2003, no pet.). There is a strong presumption that it is in the
    child’s best interest to preserve the parent-child relationship. In re 
    B.C.S., 479 S.W.3d at 927
    .
    Several factors must be considered in our analysis of the best interest issue: the child’s desires;
    the child’s emotional and physical needs now and in the future; the emotional and physical
    danger to the child now and in the future; the parenting abilities of the individuals seeking
    custody; the programs available to assist those individuals to promote the child’s best interest;
    the plans for the child by those individuals or the agency seeking custody; the stability of the
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    home or proposed placement; the parent’s acts or omissions that may indicate that the existing
    parent-child relationship is not a proper one; and any excuse for the parent’s acts or omissions.
    Holley v. Adams, 
    544 S.W.2d 367
    , 372 (Tex. 1976)(“the Holley factors”). We also must bear in
    mind that permanence is of paramount importance in considering a child’s present and future
    needs. In re 
    B.C.S., 479 S.W.3d at 927
    .
    The first factor is the desires of the child. Eddie was only twenty-one months old when
    the case was tried. Consequently, there is no evidence of his desires. This factor is neutral.
    The next two factors are the child’s emotional and physical needs now and in the future,
    and the emotional and physical danger to the children now and in the future. The need for
    permanence is a paramount consideration for a child’s present and future physical and emotional
    needs. In re R.A.G., 
    545 S.W.3d 645
    , 653 (Tex.App.--El Paso 2017, no pet.); In re 
    U.P., 105 S.W.3d at 230
    . The evidence supports the trial court’s findings that Mary knowingly placed
    Eddie in an endangering environment and that she engaged in conduct endangering to his
    physical and emotional well-being. A fact finder may infer that past conduct endangering to the
    well-being of a child may recur in the future if the child is returned to the parent. In re 
    R.A.G., 545 S.W.3d at 653
    . Based on the evidence, the trial court could have determined that the second
    and third factors weigh heavily in support of the best interest finding.
    The fourth factor is the parenting abilities of the individuals seeking custody.            In
    reviewing the parenting abilities of a parent, a factfinder can consider the parent’s past neglect or
    past inability to meet the physical and emotional needs of the child. D.O. v. Texas Department
    of Human Services, 
    851 S.W.2d 351
    , 356 (Tex.App.--Austin 1993, no writ), disapproved of on
    other grounds by In re J.F.C., 
    96 S.W.3d 256
    (Tex. 2002). We have already concluded that the
    evidence is legally and factually sufficient to support the trial court’s findings under Sections
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    161.001(b)(1)(D) and (E). While Mary completed her parenting classes, she consistently denied
    any knowledge of Eddie’s injuries. Further, she failed to act to protect her younger brother, V.J.,
    from physical abuse at the hands of Lyle. This factor weighs in favor of the best interest finding.
    The fifth factor examines the programs available to assist those individuals to promote
    the child’s best interest. The Department developed a service plan for Mary and she completed
    some of the required services. She was required to complete additional counseling, but Mary
    attended only two sessions. The counselor, Cynthia Leede, explained that part of the therapeutic
    process is taking accountability for your own actions whether it is for causing the injuries or
    leaving the child with someone else who caused the injuries. Mary did not show any degree of
    accountability during her counseling sessions. This factor provides some support for the best
    interest finding.
    We will consider the sixth and seventh factors together. The sixth factor examines the
    plans for the child by those individuals or the agency seeking custody. The seventh factor is the
    stability of the home or proposed placement. The factfinder may compare the parent’s and the
    Department’s plans for the children and determine whether the plans and expectations of each
    party are realistic or weak and ill-defined. 
    D.O., 851 S.W.2d at 356
    . Mary’s plan is to reside in
    her mother’s home with her four siblings even though she blamed her siblings for causing
    Eddie’s bruises. Mary testified that she would not allow Lyle to have contact with Eddie but
    refused to state if that was because she viewed Lyle as a risk to Eddie. Mary’s mother is ill and
    will require long-term care. Thus, it may become necessary for Mary to provide care for her
    mother and siblings.
    The Department sought to terminate Mary’s parental rights because she did not have the
    ability to protect Eddie, and it recommended that he remain in his current placement. Eddie has
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    been with his current foster parents since July or August 2018, and he is attached to them. Eddie
    has fully recovered from his injuries and is a “different child” than the one who left the hospital.
    The foster parents want to adopt him. The trial court could have determined that the foster
    parents will continue to provide a safe, stable, and nurturing home for Eddie whereas Mary’s
    plan is not realistic. The sixth and seventh factors weigh in favor of the best interest finding.
    The eighth factor is the parent’s acts or omissions that may indicate that the existing
    parent-child relationship is not a proper one. The trial court found that Mary engaged in
    endangering conduct or she failed to protect Eddie from an endangering environment. At trial,
    Mary continued to deny any knowledge of how Eddie’s injuries occurred even though she and
    Lyle were his sole caregivers. Based on this evidence, the trial court could have found that the
    existing parent-child relationship between Mary and Eddie is not a proper one because she has
    failed to demonstrate an ability or willingness to protect the child. This factor supports the best
    interest finding.
    Finally, the ninth factor is whether there is any excuse for the parent’s acts or omissions.
    The evidence in the record does not present a basis for finding an excuse for Mary’s acts or
    omissions.
    Applying the appropriate standards of review, we conclude that the trial court could have
    reached a firm conviction that termination of M.J.’s parental rights is in the best interest of the
    child. Accordingly, the evidence is both legally and factually sufficient to support the best
    interest finding. Issue Three is overruled. Having overruled each issue, we affirm the order
    terminating Mary’s parental rights to Eddie.
    August 21, 2019
    ANN CRAWFORD McCLURE, Chief Justice
    Before McClure, C.J., Rodriguez, and Palafox, JJ.
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