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Based on record review and interview, the hospital failed to inform patients, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing patient care in 2 (#2 and #4) of 5 sampled patient medical records.
Findings:

Review of hospital policy provided by S10CNO titled "Patients' Rights and Restriction of Rights Function: Rights", last reviewed 01/2023, revealed in part: "Procedure: 1. Upon admission, patient/his or her family member/or representative receives and acknowledges receipt of 'Patient Rights'."

Patient #2
Review of medical record on 12/03/2025 between 12:04 PM-1:00 PM revealed an admit date of 10/12/2025 with ongoing admission.

Review of Patient #2's "Conditions of Admission" form dated 10/12/2025, failed to reveal signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights.

During an interview on 12/03/2025 at 12:45 PM, S3NM confirmed the "Conditions of Admission" form dated 10/12/2025, failed to reveal signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights.

Patient #4
Review of medical record on 12/01/2025 between 12:54 PM and 2:15 PM and 12/03/2025 between 10:06 AM-10:30 PM revealed an admit date of 09/19/2025 and discharge date of 09/25/2025.

Review of Patient #4's "Conditions of Admission" form dated 09/19/2025, failed to reveal signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights.

During an interview on 12/03/2025 at 10:24 AM, S3NM confirmed the "Conditions of Admission" form dated 09/19/2025, failed to signatures of patient or family member/representative confirming acknowledgment of receipt of Patient Rights.

Based on record review and interview the hospital failed to ensure 2 (#1 and #5) of 5 patients sampled participated in their treatment process.
Findings:

Review of hospital policy provided by S10CNO titled "Patients' Rights and Restriction of Rights Function: Rights", last reviewed 01/2023, revealed in part: "Procedure: 7. Patient receives education regarding his/her medication and the treatment process.

Patient #1
Review of Patient #1's medical record revealed and admit date of 09/16/2025 and discharge of 09/22/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose.

Review of Patient #1's Interdisciplinary Master Treatment Plan dated 09/16/2025 last entry made on 09/17/2025 failed to reveal evidence Patient #1 or her representative participated in the treatment process.

During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #1's treatment plan did not reveal evidence Patient #1 or her representative participated in the treatment process.

Patient #5
Review of Patient #5's medical record revealed, admit date of 09/29/2025, and discharge on 11/26/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose.

Review of Patient #5's Interdisciplinary Master Treatment Plan dated 09/30/2025 with last entry made on 10/14/2025 failed to reveal evidence Patient #5 or her representative participated in the treatment process.

During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #5's treatment plan did not reveal evidence Patient #5 or her representative participated in the treatment process.

Based on record review and interview the hospital:
1) failed to ensure the right to request or refuse treatment in 1 (#1) of 5 patient medical records sampled; and
2) failed to ensure the patient or patient representative signed a consent for treatment in 1 (#2) of 5 patient medical records sampled.
Findings:

Review of hospital policy provided by S10CNO titled "Patients' Rights and Restriction of Rights Function: Rights", last reviewed 01/2023, revealed in part: ""Policy: River Oaks recognizes and respects the rights of the patient as an individual with special needs. The staff supports the patient's right to make decisions regarding his/her care. This includes discontinuing treatment. Procedure: 12. The organization respects the right of the individual served or surrogate decision-maker to refuse care treatment or services in accordance with law and regulation."

Review of hospital policy provided by S10CNO titled "Informed Consent Function: Rights", last reviewed 11/2001, revealed in part: "Policy: It is the policy of River Oaks that the patient has a right to reasonably informed participation in decisions involving their health care. To the degree possible this should be based on a clear, concise explanation of his/her condition and of all proposed treatment, including any risk of mortality or serous side-effects, problems related to recuperation and probability of success. The patient will not be subjected to any procedure without his voluntary, competent and willing consent or that of his legally authorized representative. Where medically significant alternatives for care exist the patient shall be so informed. A. Informed consent for routine hospital care: 1. General Consent: Any patient registered as inpatient will sign a general consent. 2. Evidence of informed consent: i. In-patient: an admission consent form will be executed by the patient or the patients legally recognized representative as part of the hospital's regular admission procedure."

1) Failure to ensure the right to request or refuse treatment in 1 (#1) of 5 patient medical records sampled.
Review of patient #1's medical record revealed and admit date of 09/16/2025 and discharge of 09/22/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose.

Review of History and Physical dated 09/17/2025 at 10:10 AM revealed the following in part: Allergies: No known allergies. Immunological Status: Received all Childhood immunizations. Physical Examination: Skin: without any significant skin lesion. Medical Problems: 1. Suicidal Ideation: PRN (as needed) medications and plan per psychiatry.

Review of Daily Nurse Progress Note dated 09/17/2025 between 7:00 AM and 7:00 AM on 09/18/2025 revealed patient was not having thoughts of killing herself and was not exhibiting suicidal behavior.

Review of Daily Nurse Progress Note dated 09/17/2025 at 3:20 PM revealed patient complaint of an allergic reaction to a vaccine she received before her admission at the psychiatric hospital. S7MD was notified and order was provided for one dose of ibuprofen 600 mg orally with continued monitoring.

Review of Daily Nurse Progress Note dated 09/18/2025 between 7:00 AM and 7:00 AM on 09/19/2025 revealed patient was not having thoughts of killing herself and was not exhibiting suicidal behavior.

Review of Daily Nurse Progress Note dated 09/18/2025 at 8:00 PM revealed patient was cooperative and denied suicidal ideations.

Review of Medical Consult Form signed by S7MD dated 09/19/2025 at 10:30 AM revealed the following in part: "Patient received meningitis shot in her right arm 1 day prior to arrival at our facility. Since then she has developed mild swelling, redness at site. No fever no chills no loss of sensation or strength in right arm. No additional concerns, unsure if she has ever had a reaction before." Assessment: Allergic Reaction. Plan: "localized based on exam. Will start scheduled Tylenol and ibuprofen for 2 day duration and monitor response. Patient ambulating without difficulty, normal appetite and activity level."
Continued review failed to reveal documentation that S7MD contacted Patient #1's mother to inform her of this change in condition and his treatment plan.

Review of Progress Notes dated 09/19/2025 at 5:55 PM revealed during mother's visitation with Patient #1 she was concerned about her daughter's arm and requested transfer to an emergency department for treatment. Mother wanted to know when she could be discharged. She was told the Formal Voluntary Admission was for 72 hours. S7MD was notified of mother's request for her daughter to be transferred to an emergency department for treatment. S7MD stated he did not want to send Patient #1 to an emergency department and did not want to order what the mother suggested. (Benadryl, Pepcid, and steroids).

Continued review of Patient #1's medical record failed to reveal documented safety concerns or behaviors posing risk of harm to self or others during transport from the psychiatric hospital to an emergency department in response to the mother's request for medical evaluation/treatment from a higher level of care.

During an interview on 12/03/2025 at 3:35 PM, S17Staff stated S7MD had evaluated the reaction and his professional opinion was the patient did not need to be transferred. S17Staff indicated the transfer of a patient for medical care was costly, and if the issue could be handled at the psychiatric hospital then that is the preferred path.

2) Failure to ensure the patient or patient representative signed a consent for treatment in 1 (#2) of 5 patient medical records sampled.

Review of Patient #2's medical record on 12/03/2025 between 12:04 PM-1:00 PM revealed an admit date of 10/12/2025 with ongoing admission.

Review of Patient #2's "Conditions of Admission" form dated 10/12/2025, failed to reveal the patient or patient representative signed a consent for treatment.

During an interview on 12/03/2025 at 12:45 PM, S3NM confirmed the "Conditions of Admission" form dated 10/12/2025, failed to reveal the patient or patient representative signed a consent for treatment.

Based on observation and interview the hospital failed to ensure care in a safe setting as evidenced by:
1) failure to ensure Unit 'B' was maintained at a temperature between 70-75 degrees Fahrenheit effecting the 21 (#R1-#R21) patients on the census;
2) failure to ensure Patient #2 did not have access to shoelaces that created a ligature risk; and
3) failure to ensure patients did not have access to contraband.
Findings:

Review of hospital policy provided by S10CNO titled "Patients' Rights and Restriction of Rights Function: Rights", last reviewed 01/2023, revealed in part: "Procedure: 4. Patient is provided reasonable access to care, in a safe environment."

1) Failure to ensure Unit 'B' was maintained at a temperature between 70-75 degrees Fahrenheit effecting the 21 (#R1-#R21) patients on the census.
Review of Facility Guidelines Institute 2014 edition revealed in part: Part 4 (ASHRAE 170) Patient areas (including psychiatric units) are required to maintain a temperature between 70-75 degrees Fahrenheit.

During a tour of Unit 'B' on 12/01/2025 between 9:42 AM and 9:58 AM guided by S11DPO and S18ADON, observation revealed patients in the milieu with blankets and towels wrapped around their bodies. Observation of the wall approximately twelve feet above the common area of Unit 'B' revealed a large clock reading 9:57 AM with temperature gauge measuring 66 degrees Fahrenheit. Continued observation revealed HVAC system 'C' temperature gauge in the common area of Unit 'B' on the wall approximately eye level reading 64 degrees Fahrenheit.

During an interview on 12/01/2025 at 10:00AM S11DPO and S18ADON confirmed the common area of Unit 'B' was uncomfortably cold. S11DPO and S18ADON confirmed the readings on both gauges and stated he hospital was working on the Heating,Ventilation, and Air Conditioning sytem (HVAC).

During a tour of Unit 'B' on 12/03/2025 between 4:50 PM and 4:55 PM guided by S19CEO observation of the wall, approximately twelve feet above the common area of Unit 'B' revealed the temperature gauge read 69 degrees Fahrenheit and the gauge on the wall approximately eye level, reading 67 degrees Fahrenheit. There were no patients observed on Unit 'B'.

During an interview on 12/03/2025 at 4:51 PM, S19CEO stated the patients were in the cafeteria in another building, confirmed the temperatures and stated the HVAC system was currently being worked on.

2) Failure to ensure 1 (#2) of 1 pateints sampled observed did not have access to shoelaces that created a ligature risk.
Review of hospital policy provide by S10CNO titled "Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches" last reviewed 12/2024, revealed in part: "Contraband: Ligature: string/rope/cord longer than 8 inches."

During a tour of Unit 'A' on 12/01/2025 between 9:59 AM and 10:36 AM guided by S18ADON and S3NM observations revealed Patient #2's room with a pair of tennis shoes containing shoelaces made from the strings of medical masks tied together creating a ligature risk.

During an interview on 12/01/2025 at 10:15 AM, S3NM confirmed the shoelaces in Patient #2's shoes, verified they were a ligature risk, and stated the shoelaces should be removed from his room.

3) Failure to ensure patients did not have access to contraband.
Review of hospital policy provide by S10CNO titled "Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches" last reviewed 12/2024, revealed in part: "Contraband/permissible Items: 1. Hygiene items and buckets will be provided to patients for use during hygiene times and secured in a locked location when not in use. 1.1 Shampoo. 1.5 Toothbrushes. Danger Risk: Any items which are sharp or containing metal."

During a tour of Unit 'A' on 12/01/2025 between 9:59 AM and 10:36 AM guided by S18ADON and S3NM observations revealed the following:

-Patient #R22's room contained two metal pieces that appeared to be approximately 1 inch long, rectangular shaped with sharp corners sitting on the desk.
-Room 'a' contained a paper bag with 2 latex-like exam gloves. Continued observation revealed a box of "Maxi-Pads" on the windowsill.
-Room 'b' bathroom contained 3 shampoo bottles and a toothbrush.

During an interview on 12/01/2025 at 10:20 AM, S3NM stated she believed the two metal pieces in Patient #R22's room were parts of zippers and should not be accessible to patients. S3NM confirmed the items in Room 'a' and in the bathroom of Room 'b' were considered contraband and should be restricted from patient access unless there use were observed by staff.

Based on record review and interview the hospital failed to perform adequate physical assessments on 1 (#4) of 5 patients sampled.
Findings:

Review of hospital policy provided by S10CNO titled "Assess and Reassess: Function: Nursing: Provision of Care", last reviewed 11/2023, revealed in part: Policy: All patients admitted to River Oaks Psychiatric Hospital will have a nursing assessment completed at a minimum every shift. Procedure: Assessment will include the patient's mental status and physical status. Findings will be documented. More frequent assessments may be needed when patient is having a physical problem and change of condition. Pain assessments are completed on all patients and are assessed by a nurse at a minimum per shift. Reassessment occurs with change in patients' condition, physical complaint, and patient injuries.

Review of Patient #4's medical record revealed an admit date of 09/19/2025 with admit diagnoses including auditory, visual hallucinations with depression and anxiety. Patient was discharged on 09/25/2025 with diagnoses including adjustment disorder and right hand fourth digit abscess.

Review of Patient #4's nursing notes dated 09/19/2025, 09/20/2025, 09/21/2025, 09/22/2025, and 09/23/2025 failed to reveal documentation of pain or changes to skin integrity. Each note stated "No medical issues."

Nursing Progress Note dated 09/23/2025 written by S20RN, revealed Patient #4's "mother stated she wanted her daughter to have her hand examined and if an xray is needed then do the xray. Was told by S16NP to put the patient back on the physician list for an examination. No xray done until hand is examined per mother's request."

Review of Patient #4's nursing note 09/24/2025 failed to reveal documentation of pain or changes to skin integrity. The note stated "No medical issues."

Review of Medical Consult Form signed by S16NP on 09/24/2025 at 12:00 PM revealed the following: "My finger is infected. patient has erythema and edema to her right ring finger, no purulent drainage. Reports it is tender to touch. Afebrile." Physical assessment: Right ring finger with edema [swelling] and erythema [redness] no purulent [discharging pus] drainage. Plan: "Keflex [antibiotic] 500 mg twice a day for 7 days and warm water soaks twice a day."

Nursing Progress Note dated 09/25/2025 written by S20RN, revealed the following: "I asked S7MD to reexamine Patient #4's hand this morning around 9:00 AM. He gave orders to send patient to urgent care to get her finger drained. Urgent care drained her finger and sent her with a prescription for Bactrim DS [antibiotic] 800-160 mg oral daily for 7 days. S7MD gave order to discontinue the Keflex [antibiotic] and start the Bactrim. The patient's mother was notified she returned to the unit, her finger was drained and she would be starting Bactrim."

Review of Medical Consult Form signed by S7MD on 09/25/2025 at 9:15 AM revealed the following: "Infected Finger: patient with swelling and pain with palpation of right hand fourth digit. She started on oral antibiotic however no improvement in swelling. She remains afebrile and infection appears localized. She will benefit from incision and drainage, which we are unable to do here. Will send out for treatment to urgent care."

Review of Patient #4's nursing note 09/25/2025 revealed patient was discharged to mother at 3:40 PM.

Based on record review and interview the hospital failed to ensure a completed Nursing Care plan in 2 (#1 and #5) of 5 patient medical records sampled.
Findings:

Review of hospital policy provided by S10CNO titled "Patients' Rights and Restriction of Rights Function: Rights", last reviewed 01/2023, revealed in part: "Procedure: 8. Patient's plan of treatment is individualized to his/her special needs and circumstances."

Patient #1
Review of Patient #1's medical record revealed and admit date of 09/16/2025 and discharge of 09/22/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose.

Review of Medical Consult Form signed by S7MD dated 09/19/2025 at 10:30 AM revealed the following in part: "Patient received meningitis shot in her right arm one day prior to arrival at our facility. Since then she has developed mild swelling, redness at site. No fever no chills no loss of sensation or strength in right arm. No additional concerns, unsure if she has ever had a reaction before." Assessment: Allergic Reaction. Plan: "localized based on exam. Will start scheduled Tylenol and ibuprofen for two day duration and monitor response."

Review of Medical Consult Form signed by S7MD dated 09/19/2025 at 7:45 PM revealed the following in part:
Assessment: "Allergic Reaction". Plan: "Continue Tylenol and Ibuprofen and will start scheduled Benadryl as well."

Review of Patient #1's Interdisciplinary Master Treatment Plan dated 09/16/2025 with last entry made on 09/17/2025 failed to reveal a medical problem related to Allergic Reaction.

During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #1's treatment plan did not include the medical problem related to Allergic Reaction and should have been included.

Patient #5
Review of Patient #5's medical record revealed, admit date of 09/29/2025, and discharge on 11/26/2025 with diagnoses of depression unspecified second to suicidal ideations with plan to overdose.

Review of document titled "Hospital / Licensed Provider Abuse / Neglect Initial Report" dated 11/05/2025 at 10:00 AM revealed in part: Patient #5 alleged that another male patient touched her in the thigh/groin over the clothes while in the classroom. Following the allegation, a ten foot boundary from Patient #5 was placed on the male patient although the allegation was unsubstantiated per the hospital.

Review of Patient #5's Interdisciplinary Master Treatment Plan dated 09/30/2025 with last entry made on 10/14/2025 failed to reveal a problem related to Patient #5's allegation of sexual assault.

During an interview on 12/03/2025 at 3:55 PM, S10CNO confirmed Patient #5's treatment plan did not include a problem related to Patient #5's allegation of sexual assault and should have been included.

Based on record review and interview the hospital failed to ensure the registered nurse assigned nursing care of each patient on Unit 'B'.
Findings:

Review of Nurse Assignment sheet on 12/01/2025 at 9:46 AM for Unit 'B' failed to reveal the nurse had completed the assignment sheet.

During an interview on 12/01/2025 at 9:46 AM, S21RN stated the unit had been busy and she had not had the chance to complete the nursing assignment sheet. S21RN verified the assignment sheet was supposed to be completed at shift change.

Failure to ensure nursing staff adhered to all policies and procedures as evidenced by:
1) failure to submit an incident report per hospital policy and procedure related to a patient-to-staff incident where staff was injured; and
2) failure to ensure nursing staff were educated and trained per hospital policy and procedure.
Findings:

1) Failure to submit an incident report per hospital policy and procedure related to a patient-to-staff incident involving staff injury.
Review of hospital policy provided by S10CNO titled "IR/Incident Reporting Process" last revised 09/2023, revealed in part: "V. Procedure: B. Healthcare Facility Staff 1. Any healthcare facility employee, who discovers, is directly involved in, or responds to an incident, is to complete or direct completion of an IR/Incident Report as soon after the event as possible, but not later than the end of the shift."

Review Patient #2's Nursing Progress Note dated 12/01/2025 at 5:00 PM revealed S22MHT reported to nurse that Patient #2 pushed her and she cut her wrist on a piece of metal on the unit. S22MHT notified the nurse supervisor and reported she was pressing charges against Patient #2.

Review of Incident Log on 12/03/2025 provided as complete and dated 09/01/2025 through 12/01/2025 failed to reveal an incident report was completed related to this incident.

During an interview on 12/03/2025 at 4:12 PM, S10CNO confirmed there had not been an incident report completed by staff per hospital policy and procedure as of 12/03/2025 at 4:12 PM.

2) Failure to ensure 2 (S13RN and S6MHT) of 6 nursing staff personnel files sampled were educated and trained per hospital policy and procedure.
Review of hospital policy provided by S10CNO titled "Patients' Rights and Restriction of Rights Function: Rights", last reviewed 01/2023, revealed in part: Procedure: 6. All employees receive continued education regarding the patient's right to privacy and confidentiality.

Review of hospital policy provided by S10CNO titled "Staff Competency and Training" last revised 09/2020, revealed in part: "Purpose: to assure compliance with all laws, rules and regulations relating to federal and state health care programs. Annual Retraining: On an annual basis, each employee is required to complete the following topics:
" Fire safety and Emergency Management
" Infection control
" Risk Management including patient safety
" Corporate compliance, including requirements of the ( Agreement)
" HIPAA and Confidentiality
" Code of Conduct
" Ethics
" EMTALA
" Patient/Resident Rights
" Patient/Resident Advocacy and Grievance Process
o Abuse/Neglect Identification and Reporting
Clinical/Nursing Staff will receive additional training, appropriate to their position following areas:
" Management of aggressive behaviors
" Suicide risk assessment and management
" Medical necessity of admission and continued stay
" Appropriate use of involuntary commitments
" Active and individualized treatment requirements
" Physician participation and supervision in care
" Proper use and monitoring of physical and chemical restraint and
seclusion(semi-annually for PRTF staff)
" Interdisciplinary patient/resident-centered treatment planning
" Documentation requirements
" Medical Equipment and Waived testing
Training may be accomplished via the HealthStream platform, individual in-trainings, or in person group formats based on the topic and appropriate co demonstration.
Competency Assessment
On an annual basis, each employee receives a performance evaluation assessing competence related to each job role/responsibility. Any unsatisfactory rating accompanied by a plan for improvement. Additional task-specific competency assessments may be required annually for specific tasks in various department.

Review of S13RN's personnel file revealed a date of hire of 04/18/2022 as a Registered Nurse.

Review of S13RN's Performance Evaluation dated 12/15/2024 revealed a total score of two-"Requires Improvement". Continued review revealed a Compliance score of one-"Does Not Meet Expectations". Compliance refers to in part: "Follows and abides by facility policies, procedures, and corporate compliance program as applicable to role and responsibilities. Maintains required training."

Review of S13RN's assigned training list revealed the following:
Precautions and Prevention of High risk Behaviors: Past due on 06/17/2022
Stages of Crisis: Past due 11/20/2022
Anxiety related disorders: Past due 08/01/2023
Assessing Immediate risk to Physical Safety: Past due 08/01/2023
Avoiding Power Struggles: Past due 08/01/2023
Bipolar Disorder: Past due 08/01/2023
Developing a Crisis Prevention Plan: Past due 08/01/2023
Key Points in Crisis Management: Past due 08/01/2023
Limit Setting-Supportive Redirection: Past due 08/01/2023
Post Crisis Patient Debriefing: Past due 08/01/2023
Safety Managing Altercations: Past due 08/01/2023
Schizophrenia and Psychotic Disorders: Past due 08/01/2023
Self-Assessment Before, During, and After a Crisis: Past due 08/01/2023
Substance Use Disorders: Past due 08/01/2023
Seclusion and Restraint Training (All Staff): Past due 08/01/2023
Seclusion and Restraint Training (RN): Past due 08/01/2023
Stages of Crisis Stage 4-Tension Reduction: Past due 10/31/2025
Q3 Sept Play it safe: Past due 10/31/2025
Q3 Sept Play it safe-Metal Scraps: Past due 10/31/2025
Caring for the Cognitively Impaired for Healthcare Assistants: Past due 11/20/2025.
Post Crisis Staff Debriefing: Past due 11/20/2025.

During an interview on 12/03/2025 at 1:45 PM, S2HR and S23HR confirmed S13RN received a low rating on her performance evaluation partly because of non-compliance with assigned training.

Review of S6MHT's personnel file revealed a date of hire of 02/2025 as a Mental Health Technician.

Review of S6MHT's Performance Evaluation dated 10/01/2025 revealed a total score of two-"Requires Improvement". Continued review revealed a Compliance score of one-"Does Not Meet Expectations". Compliance refers to in part: "Follows and abides by facility policies, procedures, and corporate compliance program as applicable to role and responsibilities. Maintains required training."

Review of S6MHT's assigned training list revealed the following:
Limit Setting-Supportive Redirection: Past due 06/30/2025
Stages of Crisis-Stage 2-Defensive: Past due 06/30/2025
Substance Use Disorders: Past due 06/30/2025
Stages of Crisis-Stage 3-Loss of Control/Risk: Past due 07/31/2025
Observation round policy and procedure: Past due 09/30/2025
Safety Managing Altercations: Past due 09/30/2025
Stages of Crisis Stage 4-Tension Reduction: Past due 10/31/2025
Q3 Sept Play it safe: Past due 10/31/2025
Q3 Sept Play it safe-Metal Scraps: Past due 10/31/2025
Q3 Sept Play it safe-Nemschoff Chairs: Past due 10/31/2025
Caring for the Cognitively Impaired for Healthcare Assistants: Past due 11/20/2025.
Post Crisis Staff Debriefing: Past due 11/20/2025.

During an interview on 12/03/2025 at 1:58 PM, S2HR and S23HR confirmed S6MHT received a low rating on his performance evaluation partly because of non-compliance with assigned training.