SAN ANTONIO \u2013 The federal government\u2019s own watchdog is raising serious concerns about the mental health unit at San Antonio\u2019s Audie L. Murphy Memorial Veterans\u2019 Hospital, finding safety hazards that went unresolved for years, privacy violations and widespread failures in patient care documentation.<\/p>\n
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 \u2014 and the hospital agreed with all of them.<\/p>\n
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 \u2014 with no permanent fix in sight.<\/p>\n
A separate deficiency involving paper towel dispensers, which also created a hanging risk, had been unresolved for more than four years.<\/p>\n
In May 2026, facility staff reported requesting approval for an emergency contract to address the issues, with an estimated completion date of December 2027.<\/p>\n
The report also found that VA police were monitoring and recording veterans inside the mental health unit \u2014 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.<\/p>\n
The facility also lacked a written policy governing the use of video monitoring on the unit altogether.<\/p>\n
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 \u2014 far below the 90% compliance threshold the OIG uses as a benchmark.<\/p>\n
Discharge instructions also fell short. Only 13% of records included follow-up appointment information written in plain, easy-to-understand language.<\/p>\n
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\u2019t surprise him.<\/p>\n
\u201cThe suicide and the mental health care is another area that\u2019s a challenge,\u201d Schlecht said. \u201cYou would think someone who calls a crisis line \u2014 \u2018Hey, I\u2019m going to be seen within a day or two, if not within hours.\u2019 A crisis is a crisis. It\u2019s almost a 911 event.\u201d<\/p>\n
Schlecht said the problems extend well beyond San Antonio.<\/p>\n
\u201cIt\u2019s not only in San Antonio \u2014 I\u2019m assuming at every VA,\u201d he said. \u201cPeople aren\u2019t getting the care when they need it most.\u201d<\/p>\n
In a statement, VA Press Secretary Quinn Slaven said the facility had already begun implementing the OIG\u2019s recommendations before the report was released.<\/p>\n
\u201cVA appreciates OIG\u2019s assistance in uncovering this issue which the previous administration failed to address,\u201d Slaven said. \u201cA contract was in place in August 2026 to remediate the sink, toilet and paper towel dispensers.\u201d<\/p>\n
Slaven added that the facility now ensures informed consent discussions are properly documented and that discharge instructions use clear, easy-to-understand language \u2014 both of which the OIG verified on Sept. 14, 2026.<\/p>\n
The South Texas Veterans Health Care System serves more than 123,000 veterans annually. The OIG will monitor the facility\u2019s progress on all 13 recommendations until they are completed.<\/p>\n
Read also:<\/p>\n
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