Psychiatric Hospitals Are Violating EMTALA by Turning Patients Away — ProPublica

Late one Saturday night in May 2023, Melissa Keele’s phone rang. Her son had been found alone in the desert of Colorado’s Grand Valley. He was naked; his clothes, phone, keys and car were nowhere to be found.

Keele rushed out to her own vehicle and floored it, her headlights piercing through the pitch black. For years, her son had been dealing with severe mental illness. At the peak of the COVID-19 pandemic, he hit a breaking point and attempted suicide by driving off a cliff on the highway. “God told him he needed to die,” Keele recalled him telling her.

Eventually, she picked him up — and he didn’t look good. Fearing for his safety, Keele immediately took her then-21-year-old son to West Springs Hospital in Grand Junction.

The facility, which called itself “Colorado’s Best Psychiatric Hospital,” touted “exceptional psychiatric care in a world-class environment,” including a “state-of-the-art” 63,000-square-foot facility decked out with crafts areas, light therapy rooms and “cozy nooks.”

During the intake process, Keele said she told a nurse about her son’s yearslong battle with mental illness, how he had struggled to keep up with his treatments, hold down a job and keep a roof over his head. How he had stopped taking his psychiatric medications. How just before he left that night he had told his fiancee that he wanted “some alone time” in the valley’s rolling hills.

But 102 minutes after he arrived at West Springs, a nurse discharged him.

Back at home, he slipped out a few hours later while his fiancee was at work. Police found him and quickly called his mother. He again was naked; this time, he was also sunburned and dehydrated. He couldn’t explain what had happened, and he didn’t understand why he was there. Police took him to another emergency room, which deemed him “gravely disabled.”

That determination was critical. It meant that the doctors believed sending Keele’s son home could put him in imminent danger. And it meant, legally, that they could keep him against his will until he was safe. Ultimately, he was transferred to a psychiatric hospital 240 miles east in Denver, where he stayed for more than a week.

The speed with which West Springs released him prompted federal officials to investigate the hospital for failing to properly screen and stabilize him before his discharge. Within days, regulators determined the hospital had violated federal law.

The hospital had failed to comply with the Emergency Medical Treatment and Labor Act, better known as EMTALA. The law, enacted in 1986, requires hospitals to screen and stabilize all emergency patients regardless of whether they have insurance. West Springs, the inspectors found, had missed key red flags related to Keele’s son’s grave disability, which could have left him seriously harmed.

It was the second time in a year that West Springs had violated EMTALA. In October 2022, inspectors declared that patients were in “immediate jeopardy” of harm or death because the hospital had failed to properly screen and treat 21 patients who showed up to its emergency room.

Two other times, it was cited for providing deficient emergency care in violation of other rules, according to federal regulators. Just one day after the October 2022 inspection report, regulators found that the hospital did not ensure that some low-level staff were “trained” or “qualified” to monitor patients being assessed for a crisis. And in February 2023, the hospital was hit with another violation for discharging suicidal patients without “evidence of being stabilized and deemed safe.”

In each instance, the Centers for Medicare and Medicaid Services, the agency primarily responsible for enforcing EMTALA, asked West Springs to come up with a plan for how it would ensure the problems didn’t happen again. (ProPublica requested the plans of correction in May 2025 from CMS but has not yet received the records.) CMS could have terminated the hospital’s Medicare funding. Another arm of the federal government, the inspector general of the Department of Health and Human Services, could have imposed monetary penalties for the EMTALA violations.

But neither of those things happened, though the state of Colorado increased its own oversight of the hospital, mandating that it hire an outside management company in order to keep treating patients.

West Springs Hospital did not respond to repeated inquiries from ProPublica over a year of reporting about what actions it took to prevent future EMTALA violations. In public statements, it said it was committed to providing quality care and subsequently noted that the state restored its full unconditional license at the end of 2024. Keele’s son did not respond to multiple requests for comment and we are not publishing his name; this account is based on documents and interviews with his mother.

Over 90 psychiatric hospitals across the country have violated EMTALA in the past 15 years and almost all have faced the same lack of consequences, a ProPublica investigation has found.

Since 2019, the HHS inspector general has only issued three penalties involving EMTALA violations by psychiatric hospitals. Taken together, these penalties totalled $427,000. (The inspector general has levied additional fines against medical hospitals for inadequate care of patients with mental illness.)

CMS has pulled Medicare certification, and funding, from a handful of psychiatric hospitals, and a number of others have shut down after officials threatened to stop paying. But those cases have been the exception.

“Facilities are not facing consequences for providing poor quality of care,” said Morgan Shields, an assistant professor at Washington University in St. Louis who studies the quality of care that behavioral health patients receive.

“The market isn’t punishing them and regulators are not punishing them,” Shields added. “That’s an excellent environment to make money.”

The HHS inspector general declined to comment.

For its part, CMS said that West Springs “was given the opportunity to correct their deficiencies” and subsequently “was able to demonstrate compliance.” (CMS has an online portal to report suspected EMTALA violations.)

The widespread violations of EMTALA by psychiatric hospitals — and the lack of enforcement — come even as America’s mental health crisis is reaching a fever pitch, with suicide rates near record highs.

Democrats in Congress say they are concerned that budget cuts under the Trump administration may impair oversight further. In March, the administration’s Department of Government Efficiency announced that it was shuttering half of HHS’ 10 regional offices and purging 25% of the agency’s staff.

In recent months, Rep. Lloyd Doggett, a Texas Democrat, and other members of the House and Senate have requested details on how cuts made by President Donald Trump may impact the core functions of HHS, such as ensuring compliance with regulations like EMTALA.

“The abrupt firing of so many dedicated public servants weakens the ability of the Centers for Medicare and Medicaid Services (CMS) to conduct important oversight and enforcement work,” Doggett said in a statement responding to inquiries from ProPublica, meaning that “those who violate EMTALA and other federal health and safety laws will be able to continue avoiding accountability.”

As of yet, those requests for information have gone unanswered. “CMS will continue to enforce EMTALA,” an agency spokesperson said in response to inquiries from ProPublica. The White House did not respond to requests for comment about the impact of the DOGE cuts.

“More and More Cracks”

Nearly four decades ago, a group of doctors noticed a pattern among the patients transferred into Chicago’s largest public hospital from private facilities.

Of 467 patients transferred in, 87% were brought to Cook County Hospital “because they lacked adequate medical insurance.” Some 89% of these patients were Black or Hispanic; 81% were unemployed. Almost one-quarter of these patients were medically unstable at time of transfer, and they were more than twice as likely to die as patients who weren’t transferred.

The research, published in the New England Journal of Medicine, described that “strong economic incentives” raised serious questions about for-profit hospitals’ ability to “consider the condition and well being of patients objectively.”

Within months, Congress took action.

In April 1986, President Ronald Reagan signed a law to prevent what became known as “patient dumping.” EMTALA is the only law that requires universal care for “emergency medical conditions” regardless of a person’s insurance status.

In the decades since, authorities have documented thousands of EMTALA violations by hospitals across the country.

In a number of cases, patients died just hours after failing to receive the care to which they were legally entitled.

Patients with mental health conditions have also been regularly denied emergency care, according to federal agencies. Since 2010, CMS has found more than 300 EMTALA violations by psychiatric hospitals specifically.

These include sending home gravely disabled patients like Keele’s son, turning away actively suicidal patients, screening out uninsured patients, and rejecting “frequent flyers,” those who return repeatedly, due to how they’ve interacted with staff in the past — among other issues. That’s despite the fact that, in some of these cases, patients met criteria for imminent risk of harm to themselves or others

“Most Americans take it as a given that they can get emergency health care when they go to a hospital, but that promise, enshrined in EMTALA, is showing more and more cracks,” Sen. Ron Wyden, an Oregon Democrat, said in a statement responding to inquiries from ProPublica.

“I Want Peace Again”

When hospitals release patients experiencing mental health crises prematurely or turn them away entirely, the consequences can be even more severe than what happened to Keele’s son in 2023.

Six years earlier and 1,500 miles to the southeast, Tom Swearengen was discharged from Lakeside Behavioral Health System in Memphis, Tennessee. Less than a week later, a neighbor in their leafy cul-de-sac noticed that “something seemed off” — Swearengen’s blinds had been open, for days, at all hours.

Upon entering the home, the neighbor found Tom’s body — and that of his wife, Margaret — on the living room floor. Margaret had sustained multiple gunshot wounds; Tom had suffered just one, in what police later classifed a murder-suicide.

It was a brutal end to a relationship that, in some ways, had seemed magical at the outset: A conversation kicked off at a Kroger butcher counter had blossomed, and Tom’s easygoing demeanor “put us at ease,” said Bret Boscaccy, Margaret’s son from a previous marriage, “because he seemed harmless.”

That perception changed when, one day, Margaret told Boscaccy and his brother that Tom was “losing his fight with alcoholism.” The news came as a surprise, Boscaccy recalled. “We didn’t see any of it,” he said.

On Valentine’s Day in 2017 — eight days after Tom cracked a couple ribs, split his right clavicle and bruised his lung amid a spate of drinking — he reached out for help. That’s when he and Margaret found themselves at Lakeside Behavioral.

In the ER that day, Tom’s pain was overwhelming.

“I don’t want to be here,” Tom told the Lakeside Behavioral clinician, according to a government inspection report. “I just wish something would take me. … I want peace again.” At one point in the interview, he said he wanted to hurt himself. At another, Tom described a desire to “die right now.” At a third, he shared that they had guns at home.

Under the “Suicide and Homicide/Violence Risk Factors” section of the assessment, Lakeside Behavioral’s intake clinician noted 10 distinct concerns. Tom also scored three times the threshold for hospitalization based on his recent drinking habits.

But Tom’s insurance wouldn’t cover psychiatric hospitalization, the inspection report said.

So the intake clinician called a psychiatrist, who was home, and got permission to discharge him. She characterized him as “low to no risk” of suicide or homicide. Make an appointment with your old psychiatrist, she told him. And go to Alcoholics Anonymous.

After the murder-suicide, inspectors visited the hospital and determined that the care Swearengen received violated EMTALA: There was no evidence that Lakeside Behavioral helped him in a meaningful way or that he was safe to go home.

Since August 2000, Lakeside has been owned by Universal Health Services, a for-profit corporation that operates hundreds of inpatient and outpatient behavioral health facilities, in addition to psychiatric hospitals, and made $16 billion in revenues last year. In response to inquiries about decisions made by Lakeside staff in Swearengen’s case, Universal Health Services spokesperson Jane Crawford said the company “was not going to get into details” but that it “contested the findings from CMS,” maintaining that Swearengen’s insurance status was reviewed after the medical screening exam was performed and that all EMTALA obligations were satisfied. CMS did not respond to Lakeside’s contention that its report was inaccurate, though the findings remain on the agency’s website.

The hospital did not face financial penalties after the incident and has not violated EMTALA since, according to federal inspection records. Both CMS and the HHS inspector general declined to comment on why no further action was taken against Lakeside.

About six years ago, in the effort to resolve confusion about the scope of EMTALA, federal regulators sought to make explicit that the law applies to psychiatric hospitals, even if they don’t have ERs.

“The hospital is expected to … address any immediate needs,” the July 2019 guidance from CMS read, and to “keep the patient safe and as stable as possible.”

But since the clarification, violations have continued.

The inspector general declined to comment on why so few enforcement actions have been taken since the clarification, even though CMS has cited 37 psychiatric hospitals for EMTALA violations since then. (Federal watchdogs have long said the law receives only limited enforcement. In a 2001 report, the Government Accountability Office described that “the numbers of EMTALA violations and fines have been relatively small,” and highlighted the need for “effective enforcement.”)

“The law is clear: if you want to accept taxpayer money, you must see any patient who shows up to the emergency room — regardless of their ability to pay,” said Massachusetts Sen. Elizabeth Warren, a Democrat, in a statement to ProPublica. “CMS should investigate these troubling allegations and hold accountable any hospitals that have violated the law.”

Boscaccy still remembers how he learned about his mother’s death. Five days after his stepfather was discharged by Lakeside, two unmarked police cars pulled up at Boscaccy’s home. The detectives knocked and asked if he knew who Margaret Swearengen was.

“As soon as they said that,” Boscaccy said, “I knew something bad happened.”

And when he learned from a reporter years later that Lakeside Behavioral never faced any consequences from the government, Boscaccy was at a loss.

“I’m kind of shocked that nothing happened,” he said. “You would think at least something — some kind of, something, would happen.”

“A Totally Different Place”

In December 2023, six months after he was found naked in the desert, Keele’s son hit another rough patch.

During a mental health crisis that brought him to a different emergency room, he became physically aggressive toward staffers. (After their experiences with West Springs the preceding May, Keele and her son had avoided going back.)

In June 2024, her son was arrested on a warrant for assaulting the staff and brought to jail. Since then, he’s been in and out of jail. Then the hospital. Then jail again.

“‘Spiral’ is a great word for it,” Keele said. “All this stuff ripples.”

On May 16, Keele’s son was sentenced on felony charges to three years in community corrections. Keele worries that his tumble into the criminal-legal system has “just kind of compounded” his mental illness — “It’s been a long, frustrating decline,” she said.

After the incident, West Springs experienced a period of instability.

The same month as her son was discharged prematurely, the state of Colorado put West Springs under a conditional license for a series of problematic inspections, according to reporting from the Grand Junction Daily Sentinel. Amid the scrutiny, the hospital’s parent company was required to contract with another health provider to help run it for a year. Then, in November 2024, the company’s board of directors announced a “significant new chapter”: the hospital and the organization that owns it was ceding control to Larkin Health System — a for-profit that owns three hospitals in South Florida. A month later, the state restored the hospital’s full license.

In February, however, West Springs announced that it was closing. The hospital’s parent organization cited low patient volume as one key driver of financial pressures. In March, the hospital officially shut its doors. “It is with a heavy heart that we announce the upcoming closure of West Springs Hospital,” the hospital’s parent organization wrote in a press release. “This decision was not made lightly, and we understand the profound impact it will have on our patients, staff, and community.”

Hospital officials did not respond to multiple inquiries from ProPublica for further details about the decision. Officials from Larkin Health System also declined to comment.

Keele, for her part, wonders how her son’s life might be different had he gotten the care he needed before things turned for the worse.

“I just wish I could have gotten people to work with me when this all started,” she said “We’d be in a totally different place if we had a plan — before it got so out of control.”

Keele had hoped that West Springs, under Larkin, could “turn things around.” Given that suicide rates in the Western Slope of Colorado remain well above those in the rest of the state and the U.S., their community needed to hang on to the only psychiatric facility in the region, she said. The alternative — nothing — would certainly be worse.

Now, with West Springs’ closure, that’s their reality, Keele said. And she isn’t sure what comes next. But she does know one thing.

“For those who need care,” she said, “Denver is pretty far away.”