OAG Investigation Revealed Systemic Failures in Emergency Care, Patient Safety, and Psychiatric Bed Capacity
New York Attorney General Letitia James today announced a landmark settlement with NewYork-Presbyterian Hospital (NYP) following a years-long investigation into the hospital system’s treatment of patients experiencing mental health emergencies. The Office of the Attorney General (OAG) found that NYP engaged in a repeated pattern of failures that put vulnerable patients at risk, including failing to properly evaluate and stabilize patients in emergency departments, leaving critical psychiatric beds offline during a worsening mental health crisis, and frequently diverting ambulances from bringing mental health patients to the emergency department without any defined policy in place. As a result of the investigation, NYP must implement extensive reforms to better serve emergency department patients experiencing mental health and substance use challenges and improve its screening, stabilization, and documentation procedures.
“Too many New Yorkers experiencing mental health crises have been met with inadequate care when they need help most,” said Attorney General James. “Mental health care is necessary medical care, and hospitals have a legal and moral obligation to treat these crises with urgency and compassion. These sweeping reforms will protect patients, strengthen oversight, and help ensure that no one is left without care in their most vulnerable moments.”
The OAG launched an investigation into NYP after mounting concerns regarding access to mental health care and the treatment of patients in crisis, including testimony from providers, advocates, and impacted families about dangerous gaps in emergency and inpatient psychiatric services. The OAG reviewed data regarding thousands of emergency department visits involving behavioral health conditions, as well as patient records, hospital policies, incident reporting systems, and psychiatric bed capacity data to assess compliance with federal and state law.
The investigation uncovered repeated breakdowns in emergency department care, including consistent failures to properly screen and stabilize patients with behavioral health conditions, as well as a lack of effective screening and safety measures to prevent impaired patients from leaving the hospital prior to discharge (known as elopement). The OAG also found that NYP failed to adequately monitor patients placed under observation, including those requiring one-on-one supervision, and did not consistently gather critical information from outside sources, such as family members or community providers. Patients were routinely discharged without the care, stability, or follow-up support they needed, and NYP’s records did not always include complete or accurate documentation.
In multiple cases, patients experiencing serious psychiatric symptoms — including suicidal ideation, psychosis, and violent behavior — left the hospital before being properly discharged or transferred due to inadequate supervision and safety protocols, putting both patients and the public at potential risk. For example:
- A patient with a history of suicide attempts and homicidal ideation arrived at the hospital reporting hallucinations. After telling staff he “couldn’t control when he wanted to hurt people,” he was determined to need inpatient psychiatric admission and remained in the emergency department for more than two days awaiting a bed. Despite being ordered to receive close supervision, he eloped from the hospital before he could be transferred.
- A teenage patient initially cleared for discharge pending a psychiatric evaluation was later found to need inpatient admission after providers reached his mother and determined he was at high risk for suicide or violence. Because staff had failed to implement safety precautions, the patient eloped from the hospital within minutes without receiving further care.
- A young man was brought to the hospital by EMS and police after attacking a bystander. Staff failed to review the EMS report documenting the incident and did not fully assess the risk he posed. The patient ran from the emergency department, chased by staff and security, but the hospital did not notify law enforcement until the following day.
The OAG also determined that NYP failed to bring all of its licensed inpatient psychiatric beds back online after the COVID-19 pandemic, despite clear legal requirements and growing demand for care. As of May 2023, more than 100 psychiatric beds remained out of operation across the NYP system. State regulators had directed hospitals to restore this capacity as the pandemic subsided, but NYP did not fully comply, contributing to a shortage of inpatient care during a period of heightened mental health need.
As a result of OAG’s investigation, Attorney General James is requiring sweeping reforms across the NYP hospital system, including:
- Major Emergency Department Reforms: NYP must strengthen its screening policies to identify risks such as suicide, violence, and substance use, with required follow-up assessments and ongoing reassessment for higher-risk patients. NYP must also strengthen patient safety and monitoring, including establishing mandatory observation protocols, maintaining monitoring logs, and documenting clinical decisions.
- Elopement Prevention Measures: NYP must strengthen its elopement screening policies and precautions to prevent vulnerable patients from leaving care unsupervised. If a high-need patient goes missing, staff must immediately escalate the situation, notify leadership, and fully document and review each incident.
- Health Record Upgrades: NYP must improve its electronic health record (EHR) system to ensure providers have real-time access to complete patient information and can follow care protocols.
- Care Coordination Improvements: NYP staff must review prior records, consult relevant databases, and make efforts to contact a patient’s family members, providers, or other sources when available, documenting all outreach. When appropriate, NYP must coordinate with outpatient providers and care teams before making treatment or discharge decisions.
- Stronger Discharge and Admission Planning: NYP must ensure patients with complex needs leave the hospital with appropriate follow-up care, including scheduled appointments and connections to ongoing services. NYP must also document all efforts to locate available beds for patients awaiting admission.
- Ongoing Oversight and Accountability: NYP will be subject to continued monitoring, reporting, and quality assurance reviews, including tracking and reviewing every incident of patient elopement to ensure compliance with OAG’s reforms.
Attorney General James has secured $500,000 from NYP for its misconduct and will impose a $10,000 penalty per violation for any future violations of the settlement terms. NYP must also comply with all laws governing psychiatric bed capacity and ensure appropriate planning and transparency regarding inpatient services going forward.
