by Eli Cahan for ProPublica

This article describes attempted suicide.

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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.

If you or someone you know needs help, here are a few resources:

• Call the National Suicide Prevention Lifeline: 988
• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

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........

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