SAN ANTONIO – The federal government’s own watchdog is raising serious concerns about the mental health unit at San Antonio’s Audie L. Murphy Memorial Veterans’ Hospital, finding safety hazards that went unresolved for years, privacy violations and widespread failures in patient care documentation.
The VA Office of Inspector General released the report Sept. 14, following an inspection conducted in January 2026. Inspectors identified 13 recommendations for facility leaders — and the hospital agreed with all of them.
Among the most alarming findings: Sinks and toilets inside the mental health unit had anchor points that posed a hanging risk to veterans. According to the report, appeals for those deficiencies had been repeatedly approved and in place for six years — with no permanent fix in sight.
A separate deficiency involving paper towel dispensers, which also created a hanging risk, had been unresolved for more than four years.
In May 2026, facility staff reported requesting approval for an emergency contract to address the issues, with an estimated completion date of December 2027.
The report also found that VA police were monitoring and recording veterans inside the mental health unit — without posting any signage to notify them. That practice is a direct violation of VA policy, which requires signs to be posted wherever video monitoring is in use.
The facility also lacked a written policy governing the use of video monitoring on the unit altogether.
Inspectors reviewed 50 patient records and found only 36% included documentation showing doctors discussed the risks and benefits of newly prescribed medications with veterans before administering them — far below the 90% compliance threshold the OIG uses as a benchmark.
Discharge instructions also fell short. Only 13% of records included follow-up appointment information written in plain, easy-to-understand language.
Herb Schlecht, a retired Air Force veteran who spent 25 years in uniform and has had three major heart procedures this year, said the findings don’t surprise him.
“The suicide and the mental health care is another area that’s a challenge,” Schlecht said. “You would think someone who calls a crisis line — ‘Hey, I’m going to be seen within a day or two, if not within hours.’ A crisis is a crisis. It’s almost a 911 event.”
Schlecht said the problems extend well beyond San Antonio.
“It’s not only in San Antonio — I’m assuming at every VA,” he said. “People aren’t getting the care when they need it most.”
In a statement, VA Press Secretary Quinn Slaven said the facility had already begun implementing the OIG’s recommendations before the report was released.
“VA appreciates OIG’s assistance in uncovering this issue which the previous administration failed to address,” Slaven said. “A contract was in place in August 2026 to remediate the sink, toilet and paper towel dispensers.”
Slaven added that the facility now ensures informed consent discussions are properly documented and that discharge instructions use clear, easy-to-understand language — both of which the OIG verified on Sept. 14, 2026.
The South Texas Veterans Health Care System serves more than 123,000 veterans annually. The OIG will monitor the facility’s progress on all 13 recommendations until they are completed.
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