The VA Office of Inspector General identified deficiencies in acute inpatient mental healthcare at the Audie L. Murphy Memorial Veterans’ Hospital, part of the South Texas Veterans Health Care System in San Antonio.
The findings ranged from gaps in medication consent documentation and discharge instructions to weekend programming and environmental safety issues. The OIG issued 13 recommendations, and VA said the facility had begun implementing corrective actions before the report’s release.
Here are five things to know:
1. The inspection covered five areas. The OIG conducted its inspection from January 12 through 29, 2026, reviewing leadership and organizational culture, recovery-oriented principles, clinical care coordination, suicide prevention and safety.
2. Inspectors identified documentation and discharge issues. Thirty-six percent of reviewed electronic health records included documentation of prescribers discussing medication risks and benefits with veterans before medication administration. Additionally, 13% of follow-up appointment locations and services listed in discharge instructions were described in easy-to-understand language.
3. The OIG identified programming and capacity issues. The inpatient unit did not consistently provide at least four hours of daily programming on weekends. Facility data indicated 33 operating mental health beds, though inspectors learned the unit had 25 operating beds with 2 beds out of service.
4. VA said corrective work is underway. VA Press Secretary Quinn Slaven told Becker’s the facility began implementing the OIG’s recommendations before the report was released and “will continue working to address them in the coming months.” Mr. Slaven said a contract was in place in August 2026 to remediate the sink, toilet and paper towel dispensers. He also said the facility now ensures informed consent discussions are properly documented and discharge instructions use clear, easy-to-understand language, which the OIG verified and approved Sept. 14.
5. Some recommendations have been closed. Facility staff reported a projected completion date of December 2027 for safety deficiencies. Health Service Area and Facility Directors concurred with the recommendations, and the OIG said recommendations 6 and 9 were closed.
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