According to the Office of the Attorney General, the investigation reviewed thousands of emergency department visits involving behavioral health conditions, along with patient records, hospital policies, incident reporting systems, and psychiatric bed capacity data. The OAG said it found that NYP engaged in a repeated pattern of failures that put vulnerable patients at risk.
The agency said NYP failed to properly evaluate and stabilize patients in emergency departments, left critical psychiatric beds offline during a worsening mental health crisis, and frequently diverted ambulances carrying mental health patients without any defined policy in place.
The OAG described specific patient outcomes it said flowed from those failures. One patient with a history of suicide attempts and homicidal ideation waited more than two days in the emergency department for an inpatient bed and eloped before transfer, despite orders for close supervision, according to the agency. A teenage patient eloped within minutes after staff failed to implement safety precautions, even after providers determined he was at high risk for suicide or violence, the OAG said.
The agency also said a young man brought in by EMS and police after attacking a bystander ran from the emergency department while staff gave chase, and that the hospital did not notify law enforcement until the following day.
As of May 2023, more than 100 psychiatric beds remained out of operation across the NYP system, the OAG said, even though state regulators had directed hospitals to restore that capacity as pandemic conditions subsided. The agency 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.
Under the settlement, NYP must strengthen emergency department screening policies to identify risks including suicide, violence, and substance use; establish mandatory observation protocols and monitoring logs; overhaul elopement prevention measures; upgrade its electronic health record system; expand care coordination; and ensure patients with complex needs leave with scheduled follow-up appointments. Any future violation of the settlement terms carries a $10,000 per-violation penalty.
"Too many New Yorkers experiencing mental health crises have been met with inadequate care when they need help most," James said. "Mental health care is necessary medical care, and hospitals have a legal and moral obligation to treat these crises with urgency and compassion."
Glenn Liebman, CEO of the Mental Health Association in New York State, called the settlement "an important reminder of the ongoing need for strong oversight and enforcement" and urged New York to require community hospitals to restore all inpatient capacity to pre-COVID levels. Nathan McLaughlin, Executive Director of NAMI New York State, said the findings "reflect the unfortunate reality individuals and families have experienced for years."
The matter was handled by Assistant Attorney General Michael Reisman and Assistant Attorney General and Special Assistant to the First Deputy Gina Bull, under the supervision of Health Care Bureau Chief Darsana Srinivasan.