Late one Saturday night in May 2023, Melissa Keele’s phone rang with alarming news: her son had been discovered alone in the desolate expanse of Colorado’s Grand Valley. Stripped of his clothing, he had no phone, keys, or vehicle to assist him.
Racing against time, Keele jumped into her car, her headlights cutting through the darkness. For years, her son had grappled with severe mental illness. The pressures of the COVID-19 pandemic had pushed him to a breaking point, culminating in a suicide attempt where he drove off a cliff. “God told him he needed to die,” Keele recalled him saying.
When she finally found him that night, his condition raised immediate concerns. Alarmed for his safety, Keele took her then-21-year-old son to West Springs Hospital in Grand Junction. The facility, boasting itself as “Colorado’s Best Psychiatric Hospital,” advertised “exceptional psychiatric care in a world-class environment,” featuring a “state-of-the-art” 63,000-square-foot building complete with craft areas and light therapy rooms.
During the intake process, Keele detailed her son’s long struggle with mental health issues—his inability to maintain treatment, jobs, or stable housing. He had recently stopped taking his psychiatric medications and had expressed a need for solitude before his unsettling disappearance.
However, just 102 minutes after arriving at West Springs, her son was discharged by a nurse.
Hours later, he slipped out of the house while his fiancée was at work. Police found him again—this time, he was naked, sunburned, and dehydrated. Unable to comprehend his circumstances, he was taken to another emergency room, where he was deemed “gravely disabled.” This classification was significant; it allowed doctors to keep him against his will until he was safe. Ultimately, he was transferred to a psychiatric facility in Denver, located 240 miles away, where he remained for over a week.
The rapid discharge from West Springs prompted federal officials to investigate the hospital for failing to properly screen and stabilize Keele’s son before sending him home. Within days, regulatory inspections confirmed that the hospital had violated the Emergency Medical Treatment and Labor Act (EMTALA), a crucial federal law established in 1986 that mandates hospitals to screen and stabilize all emergency patients, regardless of their insurance status. Inspectors found that West Springs overlooked critical warning signs regarding Keele’s son’s severe disability that could have resulted in serious harm.
This was not an isolated incident. It marked the second EMTALA violation for West Springs within a year. In October 2022, inspectors had already noted that patients were in “immediate jeopardy” due to the hospital’s failure to adequately screen and treat 21 patients who had presented to its emergency room. The facility received additional citations for deficient emergency care, including failing to ensure that staff were appropriately trained to monitor patients in crisis.
Despite these serious infractions, the Centers for Medicare and Medicaid Services (CMS)—the federal agency responsible for enforcing EMTALA—did not terminate West Springs’ Medicare funding or impose monetary penalties. Instead, they required the hospital to submit a plan for preventing future violations. Colorado state officials, however, stepped up oversight, mandating that the hospital hire an outside management company to continue treating patients.
West Springs Hospital did not respond to multiple requests for comment from reporters regarding their actions to prevent further EMTALA violations. In public statements, they expressed a commitment to quality care and noted that state authorities restored their full license at the end of 2024. Keele’s son, who has chosen to remain anonymous, also did not respond to requests for comment; this account is based on interviews with his mother and official documents.
The alarming reality is that over 90 psychiatric hospitals across the United States have violated EMTALA in the past 15 years, and nearly all have faced minimal consequences. Since 2019, the HHS inspector general has only issued three penalties for EMTALA violations involving psychiatric hospitals, amounting to $427,000. While some psychiatric facilities have lost Medicare certification due to violations, most have not faced such drastic repercussions.
“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 for behavioral health patients. “The market isn’t punishing them and regulators are not punishing them. That’s an excellent environment to make money.”
As the mental health crisis in America escalates, with suicide rates nearing historic highs, congressional Democrats are increasingly alarmed at the implications of budget cuts made during the Trump administration that threaten oversight of facilities like West Springs. In March, the Department of Government Efficiency announced it would close half of HHS’s ten regional offices and cut 25% of its workforce.
Representatives like Lloyd Doggett, a Texas Democrat, have raised concerns that these cuts may undermine the core functions of HHS, including the enforcement of federal regulations like EMTALA. “The abrupt firing of so many dedicated public servants weakens the ability of the Centers for Medicare and Medicaid Services to conduct important oversight and enforcement work,” Doggett stated, emphasizing that those who violate EMTALA may evade accountability.
As of now, these requests for information regarding the impact of budget cuts have gone unanswered. “CMS will continue to enforce EMTALA,” an agency representative stated in a response to inquiries. However, the White House has not commented on the budget cuts’ effects.
The prevalence of EMTALA violations by psychiatric hospitals, coupled with the lack of enforcement, coincides with a national mental health crisis. Hospitals are increasingly turning away patients in need, raising urgent questions about the adequacy of emergency mental health care in the United States.
Melissa Keele reflects on her son’s struggles and worries about how his life might have unfolded differently if he had received appropriate care when he needed it most. “I just wish I could have gotten people to work with me when this all started,” she lamented. “We’d be in a totally different place if we had a plan—before it got so out of control.”
Now, with West Springs’ closure, the community is left grappling with the stark reality of a lack of local psychiatric care. “For those who need care,” Keele said, “Denver is pretty far away.”
