A new report this week from the Department of Veterans Affairs Office of the Inspector General found mental health care at San Antonio’s Audie L. Murphy Memorial Veterans Hospital failed to meet the agency’s standards in several categories.
The OIG conducted an on-site visit to the hospital for two weeks in January and released its recommendations and findings in a public report on Sept. 14.
The evaluation comes after two service members, U.S. Marine veteran Enrique Ramos Jr. and U.S. Navy veteran Mark Miller, died by suicide in the parking lot of the hospital last year.
The report from the independent oversight division looked at hospital leadership, recovery-oriented principles, clinical care coordination, suicide prevention and safety for mental health care at Audie Murphy. In three categories, only some standards were met, and the OIG issued 13 total recommendations for improved care.
“Prior to the release of the report, VA began taking corrective action to address the issues identified by the Office of the Inspector General and is on track to complete them in the coming months,” a South Texas VA spokesperson told the San Antonio Report on Thursday.
“We appreciate the assistance of our oversight partner in improving services and care for the veterans we serve.”
The South Texas Veterans Health Care System serves more than 160,000 veterans, with Audie Murphy being its main medical center. San Antonio officials have for years said the 53-year-old facility can no longer meet the needs of the city’s growing veteran population.
They’ve had some success at sounding the alarm — leaders in Washington have appropriated $30 million for a new hospital, but the funding still needs to be approved by the Senate. VA Secretary Doug Collins swung through San Antonio earlier this year and also indicated his support for the project.
Environment violations
The watchdog report found that camera use and recording practices were not in compliance with Veterans Health Administration (VHA) directives. VA police recorded and monitored activity in the inpatient unit, against agency policy that only permits video monitoring, not recording, for VA healthcare staff only.
Additionally, the unit lacked the required signage to notify veterans that monitoring was in progress. A lack of standard monitoring practices increased privacy violation risks, the report found.
The physical treatment space also did not meet most VHA standards for a safe, hopeful and healing environment. The location lacked natural lighting, artwork or warm paint colors, things found to improve patient well-being.
The associate chief of staff for mental health said the unit appeared “very old and institutionalized.”
Facility data prior to the inspection had indicated the hospital was operating with 33 inpatient mental health beds, the OIG found that the unit only had 25 beds, two of which were out of service due to water leakage.
This contributed to diverting veterans to other hospitals for care when there were no available beds.
Further, at the date of inspection the facility had six appeals for unresolved safety issues in the inpatient unit.
“Appeals had been repeatedly approved and in place for six years for deficiencies related to sinks and toilets with anchor points that created safety risks for veteran hanging,” the report found.
An appeal for paper towel dispensers, which also created a risk for veteran suicide, had been in place for four-plus years. Appeals are submitted when a facility has identified a risk, but it is unable to correct it within six months.
“According to engineering staff, a contract was in place to address deficiencies related to toilets, sinks, and paper towel dispensers; however, the contract was terminated due to not having the materials essential for completion of the work,” the report noted.
In the meantime, staff had risk mitigation plans in place, such as completing 15-minute observation checks. The chief nurse of mental health said this strategy placed an “ongoing burden” on staff. There was also no means in place of documenting if these checks occurred at the time.
At the OIG’s request, a document was established to confirm checks, and the facility now estimates a completion date of December 2027 to address the noted problems.
“The delay in resolving deficiencies in the physical environment perpetuates significant safety risks to veterans on the inpatient unit,” the report said.
Treatment failures
Only 36% of reviewed health records confirmed that prescribers discussed medication risks and benefits with veterans prior to them receiving said treatment, the report found. Medication risk identification is mandated by the VHA.
Policy requires documentation of informed consent between patient and doctor for newly prescribed central nervous system medications, which can be used to treat psychiatric and neurological conditions.
Mark Miller’s obituary raised concern about this issue.
“Severe depression once again engulfed him and he went to the VA for help, wanting to be admitted for treatment. Instead of the care he deserved, after just 5 minutes of consultation, the provider gave him a bottle of mind-altering drugs,” it read.
His family said his last wish was to encourage the VA mental health system to stop prescribing “dangerous drugs” to veterans struggling with depression or PTSD.
“When providers do not communicate the risks and benefits of medication, veterans may not have sufficient information needed to make informed decisions about their treatment options,” the OIG report found.
Additionally, only 13% of discharge instructions with follow-up services and appointments were written in easy-to-understand language to help veterans continue to receive the necessary care.
While the inpatient unit offered the required recovery programing during weekdays, staff schedules contributed to a failure to offer the minimum of four hours of daily programming on weekends.
Staff shortages
At the beginning of the second Trump administration, mass layoffs at the VA were announced, which have potentially contributed to even longer wait times for veterans seeking care. Congressional estimates put the total amount of cuts in FY2025 at roughly 40,000 employees, though the Trump administration has proposed cutting up to 80,000.
A February report from the Center on Budget and Policy Priorities found that over the course of 2025, Texas lost 2,200 VA staff jobs, more than any other state.
Leaders at Audie Murphy identified these cuts as a barrier to staff retention.
“Facility and mental health leaders identified administrative changes such as position cuts, a hiring freeze, voluntary early retirement, and return-to-office as recruitment and retention barriers,” the report noted.
The report also found that while some of the required trainings were being attended by staff, attendance was not submitted, making monitoring difficult. The required staff did not complete the Mental Health Environment of Care Checklist training
“Environmental hazards may go unrecognized and unabated,” the report said if these practices continue.
In 2023, Audie Murphy was also the subject of an OIG inspection after a patient had died by suicide just minutes after a text conversation with the hospital’s crisis line. That report provided 14 recommendations which were completed by the end of 2025.
Last week, the VA OIG released a separate information report on staffing shortages across the country, including for the South Texas Veterans Health Care System as a whole. It found that at the San Antonio hospital, 34 occupations were designated as having severe staff shortages.
Across the nation VHA officials reported 86% of facilities had severe shortages for nurse occupations and 97% had severe occupational staffing shortages for medical officer occupations, both of which are essential for quality care.
Severe staff shortages signify how difficult a job is to fill, not an exact vacancy. 139 VHA facilities reported at least one.
The staffing shortage report is congressionally mandated annually, the total number of reported severe shortages has risen in recent years from 2,959 in FY2024, to 4,434 in FY25 and 4,712 in FY26.
Recommendations
The OIG issued 13 recommendations for the hospital, two of which have already been addressed. Staff submitted an updated letter with the accurate number of beds in service and added the required video monitoring signage.
The hospital concurred with all of the advised recommendations, and the OIG said it will follow up until all of the remaining open recommendations are met.
Additionally, the report found that the hospital did meet the proper standard of care for the leadership and suicide prevention categories, so no recommendations were issued for those sections.
In the remaining three categories, the hospital met some requirements, but not all. The recommendations address areas in which Audie Murphy is not meeting standards.
Target dates for completion of the remaining 11 recommendations were set, all estimate a completion date before or on December 2027, with several estimating completion by the end of 2026.
The San Antonio Report’s military and veterans coverage is supported by Report for America.
