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This article describes attempted suicide.<\/p>\n
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they\u2019re published.<\/p>\n
Late one Saturday night in May 2023, Melissa Keele\u2019s phone rang. Her son had been found alone in the desert of Colorado\u2019s Grand Valley. He was naked; his clothes, phone, keys and car were nowhere to be found.<\/p>\n
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. \u201cGod told him he needed to die,\u201d Keele recalled him telling her.<\/p>\n
Eventually, she picked him up \u2014 and he didn\u2019t look good. Fearing for his safety, Keele immediately took her then-21-year-old son to West Springs Hospital in Grand Junction.<\/p>\n
If you or someone you know needs help, here are a few resources:<\/p>\n
The facility, which called itself \u201cColorado\u2019s Best Psychiatric Hospital,\u201d touted \u201cexceptional psychiatric care in a world-class environment,\u201d including a \u201cstate-of-the-art\u201d 63,000-square-foot facility decked out with crafts areas, light therapy rooms and \u201ccozy nooks.\u201d<\/p>\n
During the intake process, Keele said she told a nurse about her son\u2019s 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 \u201csome alone time\u201d in the valley\u2019s rolling hills.<\/p>\n
But 102 minutes after he arrived at West Springs, a nurse discharged him.<\/p>\n
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\u2019t explain what had happened, and he didn\u2019t understand why he was there. Police took him to another emergency room, which deemed him \u201cgravely disabled.\u201d<\/p>\n
That determination was critical. It meant that the doctors believed sending Keele\u2019s 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.<\/p>\n
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.<\/p>\n
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\u2019s son\u2019s grave disability, which could have left him seriously harmed.<\/p>\n
It was the second time in a year that West Springs had violated EMTALA. In October 2022, inspectors declared that patients were in \u201cimmediate jeopardy\u201d of harm or death because the hospital had failed to properly screen and treat 21 patients who showed up to its emergency room.<\/p>\n
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 \u201ctrained\u201d or \u201cqualified\u201d to monitor patients being assessed for a crisis. And in February 2023, the hospital was hit with another violation for discharging suicidal patients without \u201cevidence of being stabilized and deemed safe.\u201d<\/p>\n
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\u2019t 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\u2019s 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.<\/p>\n
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.<\/p>\n
First image: A road near where Melissa Keele\u2019s son attempted suicide during the peak of the COVID-19 pandemic. Second image: West Springs Hospital in Grand Junction, Colorado, violated a federal law guaranteeing emergency treatment on two separate occasions in one year.<\/span><\/p>\n 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\u2019s 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.<\/p>\n 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.<\/p>\n 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.)<\/p>\n 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.<\/p>\n \u201cFacilities are not facing consequences for providing poor quality of care,\u201d said Morgan Shields, an assistant professor at Washington University in St. Louis who studies the quality of care that behavioral health patients receive.<\/p>\n \u201cThe market isn\u2019t punishing them and regulators are not punishing them,\u201d Shields added. \u201cThat\u2019s an excellent environment to make money.\u201d<\/p>\n The HHS inspector general declined to comment.<\/p>\n For its part, CMS said that West Springs \u201cwas given the opportunity to correct their deficiencies\u201d and subsequently \u201cwas able to demonstrate compliance.\u201d (CMS has an online portal to report suspected EMTALA violations.)<\/p>\n The widespread violations of EMTALA by psychiatric hospitals \u2014 and the lack of enforcement \u2014 come even as America\u2019s mental health crisis is reaching a fever pitch, with suicide rates near record highs.<\/p>\n Democrats in Congress say they are concerned that budget cuts under the Trump administration may impair oversight further. In March, the administration\u2019s Department of Government Efficiency announced that it was shuttering half of HHS\u2019 10 regional offices and purging 25% of the agency\u2019s staff.<\/p>\n 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.<\/p>\n \u201cThe 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,\u201d Doggett said in a statement responding to inquiries from ProPublica, meaning that \u201cthose who violate EMTALA and other federal health and safety laws will be able to continue avoiding accountability.\u201d<\/p>\n As of yet, those requests for information have gone unanswered. \u201cCMS will continue to enforce EMTALA,\u201d 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.<\/p>\n Numerous Psychiatric Hospitals Have Repeatedly Violated Emergency Care Regulations<\/p>\n Psychiatric hospitals that have been cited for violating the Emergency Medical Treatment and Labor Act since 2019.<\/p>\n Nearly four decades ago, a group of doctors noticed a pattern among the patients transferred into Chicago\u2019s largest public hospital from private facilities.<\/p>\n Of 467 patients transferred in, 87% were brought to Cook County Hospital \u201cbecause they lacked adequate medical insurance.\u201d 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\u2019t transferred.<\/p>\n The research, published in the New England Journal of Medicine, described that \u201cstrong economic incentives\u201d raised serious questions about for-profit hospitals\u2019 ability to \u201cconsider the condition and well being of patients objectively.\u201d<\/p>\n Within months, Congress took action.<\/p>\n In April 1986, President Ronald Reagan signed a law to prevent what became known as \u201cpatient dumping.\u201d EMTALA is the only law that requires universal care for \u201cemergency medical conditions\u201d regardless of a person\u2019s insurance status.<\/p>\n In the decades since, authorities have documented thousands of EMTALA violations by hospitals across the country.<\/p>\n In a number of cases, patients died just hours after failing to receive the care to which they were legally entitled.<\/p>\n 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.<\/p>\n These include sending home gravely disabled patients like Keele\u2019s son, turning away actively suicidal patients, screening out uninsured patients, and rejecting \u201cfrequent flyers,\u201d those who return repeatedly, due to how they\u2019ve interacted with staff in the past \u2014 among other issues. That\u2019s despite the fact that, in some of these cases, patients met criteria for imminent risk of harm to themselves or others<\/p>\n \u201cMost 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,\u201d Sen. Ron Wyden, an Oregon Democrat, said in a statement responding to inquiries from ProPublica.<\/p>\n 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\u2019s son in 2023.<\/p>\n 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 \u201csomething seemed off\u201d \u2014 Swearengen\u2019s blinds had been open, for days, at all hours.<\/p>\n Upon entering the home, the neighbor found Tom\u2019s body \u2014 and that of his wife, Margaret \u2014 on the living room floor. Margaret had sustained multiple gunshot wounds; Tom had suffered just one, in what police later classifed a murder-suicide.<\/p>\n 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\u2019s easygoing demeanor \u201cput us at ease,\u201d said Bret Boscaccy, Margaret\u2019s son from a previous marriage, \u201cbecause he seemed harmless.\u201d<\/p>\n That perception changed when, one day, Margaret told Boscaccy and his brother that Tom was \u201closing his fight with alcoholism.\u201d The news came as a surprise, Boscaccy recalled. \u201cWe didn\u2019t see any of it,\u201d he said.<\/p>\n A family photo album shows images from early in Tom Swearengen\u2019s marriage to Margaret.<\/span><\/p>\n On Valentine\u2019s Day in 2017 \u2014 eight days after Tom cracked a couple ribs, split his right clavicle and bruised his lung amid a spate of drinking \u2014 he reached out for help. That\u2019s when he and Margaret found themselves at Lakeside Behavioral.<\/p>\n In the ER that day, Tom\u2019s pain was overwhelming.<\/p>\n \u201cI don\u2019t want to be here,\u201d Tom told the Lakeside Behavioral clinician, according to a government inspection report. \u201cI just wish something would take me. \u2026 I want peace again.\u201d At one point in the interview, he said he wanted to hurt himself. At another, Tom described a desire to \u201cdie right now.\u201d At a third, he shared that they had guns at home.<\/p>\n Under the \u201cSuicide and Homicide\/Violence Risk Factors\u201d section of the assessment, Lakeside Behavioral\u2019s intake clinician noted 10 distinct concerns. Tom also scored three times the threshold for hospitalization based on his recent drinking habits.<\/p>\n But Tom\u2019s insurance wouldn\u2019t cover psychiatric hospitalization, the inspection report said.<\/p>\n So the intake clinician called a psychiatrist, who was home, and got permission to discharge him. She characterized him as \u201clow to no risk\u201d of suicide or homicide. Make an appointment with your old psychiatrist, she told him. And go to Alcoholics Anonymous.<\/p>\n 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.<\/p>\n 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\u2019s case, Universal Health Services spokesperson Jane Crawford said the company \u201cwas not going to get into details\u201d but that it \u201ccontested the findings from CMS,\u201d maintaining that Swearengen\u2019s insurance status was reviewed after the medical screening exam was performed and that all EMTALA obligations were satisfied. CMS did not respond to Lakeside\u2019s contention that its report was inaccurate, though the findings remain on the agency\u2019s website.<\/p>\n 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.<\/p>\n Lakeside Behavioral Health<\/span><\/p>\n 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\u2019t have ERs.<\/p>\n \u201cThe hospital is expected to \u2026 address any immediate needs,\u201d the July 2019 guidance from CMS read, and to \u201ckeep the patient safe and as stable as possible.\u201d<\/p>\n But since the clarification, violations have continued.<\/p>\n 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 \u201cthe numbers of EMTALA violations and fines have been relatively small,\u201d and highlighted the need for \u201ceffective enforcement.\u201d)<\/p>\n \u201cThe law is clear: if you want to accept taxpayer money, you must see any patient who shows up to the emergency room \u2014 regardless of their ability to pay,\u201d said Massachusetts Sen. Elizabeth Warren, a Democrat, in a statement to ProPublica. \u201cCMS should investigate these troubling allegations and hold accountable any hospitals that have violated the law.\u201d<\/p>\n Boscaccy still remembers how he learned about his mother\u2019s death. Five days after his stepfather was discharged by Lakeside, two unmarked police cars pulled up at Boscaccy\u2019s home. The detectives knocked and asked if he knew who Margaret Swearengen was.<\/p>\n \u201cAs soon as they said that,\u201d Boscaccy said, \u201cI knew something bad happened.\u201d<\/p>\n And when he learned from a reporter years later that Lakeside Behavioral never faced any consequences from the government, Boscaccy was at a loss.<\/p>\n \u201cI\u2019m kind of shocked that nothing happened,\u201d he said. \u201cYou would think at least something \u2014 some kind of, something, would happen.\u201d<\/p>\n Bret Boscaccy at his home. Boscaccy\u2019s stepfather murdered his mother before killing himself, according to police.<\/span><\/p>\n In December 2023, six months after he was found naked in the desert, Keele\u2019s son hit another rough patch.<\/p>\n 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.)<\/p>\n In June 2024, her son was arrested on a warrant for assaulting the staff and brought to jail. Since then, he\u2019s been in and out of jail. Then the hospital. Then jail again.<\/p>\n \u201c\u2018Spiral\u2019 is a great word for it,\u201d Keele said. \u201cAll this stuff ripples.\u201d<\/p>\n On May 16, Keele\u2019s son was sentenced on felony charges to three years in community corrections. Keele worries that his tumble into the criminal-legal system has \u201cjust kind of compounded\u201d his mental illness \u2014 \u201cIt\u2019s been a long, frustrating decline,\u201d she said.<\/p>\n After the incident, West Springs experienced a period of instability.<\/p>\n 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\u2019s parent company was required to contract with another health provider to help run it for a year. Then, in November 2024, the company\u2019s board of directors announced a \u201csignificant new chapter\u201d: the hospital and the organization that owns it was ceding control to Larkin Health System \u2014 a for-profit that owns three hospitals in South Florida. A month later, the state restored the hospital\u2019s full license.<\/p>\n In February, however, West Springs announced that it was closing. The hospital\u2019s parent organization cited low patient volume as one key driver of financial pressures. In March, the hospital officially shut its doors. \u201cIt is with a heavy heart that we announce the upcoming closure of West Springs Hospital,\u201d the hospital\u2019s parent organization wrote in a press release. \u201cThis decision was not made lightly, and we understand the profound impact it will have on our patients, staff, and community.\u201d<\/p>\n \n ProPublica and Other News Organizations Fight to Unseal Texas AG Ken Paxton\u2019s Divorce Records<\/strong>\n <\/p>\n 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.<\/p>\n Keele, for her part, wonders how her son\u2019s life might be different had he gotten the care he needed before things turned for the worse.<\/p>\n \u201cI just wish I could have gotten people to work with me when this all started,\u201d she said \u201cWe\u2019d be in a totally different place if we had a plan \u2014 before it got so out of control.\u201d<\/p>\n Keele had hoped that West Springs, under Larkin, could \u201cturn things around.\u201d 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 \u2014 nothing \u2014 would certainly be worse.<\/p>\n Now, with West Springs\u2019 closure, that\u2019s their reality, Keele said. And she isn\u2019t sure what comes next. But she does know one thing.<\/p>\n \u201cFor those who need care,\u201d she said, \u201cDenver is pretty far away.\u201d<\/p>\n This reporting was supported by the McGraw Center for Business Journalism at the City University of New York\u2019s Newmark Graduate School of Journalism, the Fund for Investigative Journalism, and the National Institute for Health Care Management Foundation.<\/p>\n","protected":false},"excerpt":{"rendered":" This article describes attempted suicide. ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they\u2019re published. Late one Saturday night in May 2023, Melissa Keele\u2019s phone rang. Her son had been found alone in the desert of Colorado\u2019s Grand Valley. He was naked; his<\/p>\n","protected":false},"author":1,"featured_media":23057,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[55],"tags":[14104,178,1476,247,9262,291,4492],"class_list":{"0":"post-23056","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-social-issues","8":"tag-emtala","9":"tag-hospitals","10":"tag-patients","11":"tag-propublica","12":"tag-psychiatric","13":"tag-turning","14":"tag-violating"},"_links":{"self":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/23056","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=23056"}],"version-history":[{"count":0,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/posts\/23056\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=\/wp\/v2\/media\/23057"}],"wp:attachment":[{"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=23056"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=23056"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/naijaglobalnews.org\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=23056"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
\n Credit: <\/span>
\n Rachel Woolf for ProPublica
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\n Credit: <\/span>
\n Source: Centers for Medicare and Medicaid Services
\n <\/span><\/p>\n\u201cMore and More Cracks\u201d<\/h3>\n
\u201cI Want Peace Again\u201d<\/h3>\n
\n Credit: <\/span>
\n Andrea Morales for ProPublica
\n <\/span><\/p>\n
\n Credit: <\/span>
\n Andrea Morales for ProPublica
\n <\/span><\/p>\n
\n Credit: <\/span>
\n Andrea Morales for ProPublica
\n <\/span><\/p>\n\u201cA Totally Different Place\u201d<\/h3>\n