A brand new report this week from the Division of Veterans Affairs Workplace of the Inspector Basic discovered psychological well being care at San Antonio’s Audie L. Murphy Memorial Veterans Hospital failed to satisfy the company’s requirements in a number of classes.
The OIG performed an on-site go to to the hospital for 2 weeks in January and launched its suggestions and findings in a public report on Sept. 14.
The analysis comes after two service members, U.S. Marine veteran Enrique Ramos Jr. and U.S. Navy veteran Mark Miller, died by suicide within the car parking zone of the hospital final 12 months.
The report from the unbiased oversight division checked out hospital management, recovery-oriented ideas, scientific care coordination, suicide prevention and security for psychological well being care at Audie Murphy. In three classes, just some requirements had been met, and the OIG issued 13 complete suggestions for improved care.
“Previous to the discharge of the report, VA started taking corrective motion to handle the problems recognized by the Workplace of the Inspector Basic and is on observe to finish them within the coming months,” a South Texas VA spokesperson informed the San Antonio Report on Thursday.
“We respect the help of our oversight companion in enhancing companies and look after the veterans we serve.”
The South Texas Veterans Well being Care System serves greater than 160,000 veterans, with Audie Murphy being its foremost medical heart. San Antonio officers have for years stated the 53-year-old facility can now not meet the wants of the town’s rising veteran inhabitants.
They’ve had some success at sounding the alarm — leaders in Washington have appropriated $30 million for a brand new hospital, however the funding nonetheless must be accredited by the Senate. VA Secretary Doug Collins swung via San Antonio earlier this 12 months and in addition indicated his assist for the undertaking.
Atmosphere violations
The watchdog report discovered that digital camera use and recording practices weren’t in compliance with Veterans Well being Administration (VHA) directives. VA police recorded and monitored exercise within the inpatient unit, in opposition to company coverage that solely permits video monitoring, not recording, for VA healthcare workers solely.
Moreover, the unit lacked the required signage to inform veterans that monitoring was in progress. An absence of normal monitoring practices elevated privateness violation dangers, the report discovered.
The bodily therapy house additionally didn’t meet most VHA requirements for a protected, hopeful and therapeutic atmosphere. The placement lacked pure lighting, art work or heat paint colours, issues discovered to enhance affected person well-being.
The affiliate chief of workers for psychological well being stated the unit appeared “very outdated and institutionalized.”
Facility information previous to the inspection had indicated the hospital was working with 33 inpatient psychological well being beds, the OIG discovered that the unit solely had 25 beds, two of which had been out of service on account of water leakage.
This contributed to diverting veterans to different hospitals for care when there have been no obtainable beds.
Additional, on the date of inspection the power had six appeals for unresolved questions of safety within the inpatient unit.
“Appeals had been repeatedly accredited and in place for six years for deficiencies associated to sinks and bathrooms with anchor factors that created security dangers for veteran hanging,” the report discovered.
An attraction for paper towel dispensers, which additionally created a threat for veteran suicide, had been in place for four-plus years. Appeals are submitted when a facility has recognized a threat, however it’s unable to right it inside six months.
“Based on engineering workers, a contract was in place to handle deficiencies associated to bathrooms, sinks, and paper towel dispensers; nevertheless, the contract was terminated on account of not having the supplies important for completion of the work,” the report famous.
Within the meantime, workers had threat mitigation plans in place, equivalent to finishing 15-minute statement checks. The chief nurse of psychological well being stated this technique positioned an “ongoing burden” on workers. There was additionally no means rather than documenting if these checks occurred on the time.
On the OIG’s request, a doc was established to verify checks, and the power now estimates a completion date of December 2027 to handle the famous issues.
“The delay in resolving deficiencies within the bodily atmosphere perpetuates vital security dangers to veterans on the inpatient unit,” the report stated.
Remedy failures
Solely 36% of reviewed well being data confirmed that prescribers mentioned treatment dangers and advantages with veterans previous to them receiving stated therapy, the report discovered. Treatment threat identification is remitted by the VHA.
Coverage requires documentation of knowledgeable consent between affected person and physician for newly prescribed central nervous system drugs, which can be utilized to deal with psychiatric and neurological circumstances.
Mark Miller’s obituary raised concern about this situation.
“Extreme despair as soon as once more engulfed him and he went to the VA for assist, eager to be admitted for therapy. As a substitute of the care he deserved, after simply 5 minutes of session, the supplier gave him a bottle of mind-altering medicine,” it learn.
His household stated his final want was to encourage the VA psychological well being system to cease prescribing “harmful medicine” to veterans battling despair or PTSD.
“When suppliers don’t talk the dangers and advantages of treatment, veterans might not have enough data wanted to make knowledgeable selections about their therapy choices,” the OIG report discovered.
Moreover, solely 13% of discharge directions with follow-up companies and appointments had been written in easy-to-understand language to assist veterans proceed to obtain the mandatory care.
Whereas the inpatient unit provided the required restoration programing throughout weekdays, workers schedules contributed to a failure to supply the minimal of 4 hours of each day programming on weekends.
Employees shortages
Initially of the second Trump administration, mass layoffs on the VA had been introduced, which have doubtlessly contributed to even longer wait occasions for veterans looking for care. Congressional estimates put the whole quantity of cuts in FY2025 at roughly 40,000 staff, although the Trump administration has proposed chopping as much as 80,000.
A February report from the Heart on Funds and Coverage Priorities discovered that over the course of 2025, Texas misplaced 2,200 VA workers jobs, greater than some other state.
Leaders at Audie Murphy recognized these cuts as a barrier to workers retention.
“Facility and psychological well being leaders recognized administrative modifications equivalent to place cuts, a hiring freeze, voluntary early retirement, and return-to-office as recruitment and retention boundaries,” the report famous.
The report additionally discovered that whereas a few of the required trainings had been being attended by workers, attendance was not submitted, making monitoring tough. The required workers didn’t full the Psychological Well being Atmosphere of Care Guidelines coaching
“Environmental hazards might go unrecognized and unabated,” the report stated if these practices proceed.
In 2023, Audie Murphy was additionally the topic of an OIG inspection after a affected person had died by suicide simply minutes after a textual content dialog with the hospital’s disaster line. That report offered 14 suggestions which had been accomplished by the top of 2025.
Final week, the VA OIG launched a separate data report on staffing shortages throughout the nation, together with for the South Texas Veterans Well being Care System as an entire. It discovered that on the San Antonio hospital, 34 occupations had been designated as having extreme workers shortages.
Throughout the nation VHA officers reported 86% of services had extreme shortages for nurse occupations and 97% had extreme occupational staffing shortages for medical officer occupations, each of that are important for high quality care.
Extreme workers shortages signify how tough a job is to fill, not a precise emptiness. 139 VHA services reported no less than one.
The staffing scarcity report is congressionally mandated yearly, the whole variety of reported extreme shortages has risen in recent times from 2,959 in FY2024, to 4,434 in FY25 and 4,712 in FY26.
Suggestions
The OIG issued 13 suggestions for the hospital, two of which have already been addressed. Employees submitted an up to date letter with the correct variety of beds in service and added the required video monitoring signage.
The hospital concurred with all the suggested suggestions, and the OIG stated it should observe up till all the remaining open suggestions are met.
Moreover, the report discovered that the hospital did meet the right normal of look after the management and suicide prevention classes, so no suggestions had been issued for these sections.
Within the remaining three classes, the hospital met some necessities, however not all. The suggestions deal with areas through which Audie Murphy just isn’t assembly requirements.
Goal dates for completion of the remaining 11 suggestions had been set, all estimate a completion date earlier than or on December 2027, with a number of estimating completion by the top of 2026.
The San Antonio Report’s navy and veterans protection is supported by Report for America.
