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Based on document review, observation, and interview, the surgical services staff did not follow Operating Room (OR) attire policy and procedure in four (4) of six (6) OR observations.

Findings:

The facility policy and procedure (P&P) titled, "Surgical Attire Peri-Operative and Invasive Procedures with Implants," last revised on 06/15/2023, stated: "Earrings should be totally confined within the head covering/scrub attire. Jewelry that cannot be contained or confined within the scrub attire should not be worn...individuals with beard or facial hair must ensure that all hair is covered within their hood or a beard cover prior to donning a mask."

Observation of Registered Nurses (RNs), Certified Registered Nurse Anesthetist (CRNAs), Anesthesiologists, Attending Physicians, and Resident Physicians in the facility's Main OR, during a tour between 11:00AM and 12:34PM on 07/30/2025, identified the following during sterile surgical procedures:

- OR #9: Staff with visible earrings exposed and beard uncovered.
- OR #10: Staff with visible dangling earrings exposed.
- OR #16: Staff with visible dangling earrings exposed.
- OR #12: Staff with visible earrings exposed.

These observations were made in the presence of Staff B (Administrator).

During interview of Staff B on 07/30/2025 at 12:34PM, Staff B confirmed these findings and stated that exposed earrings were an acceptable practice according to the Association of Peri-Operative Registered Nurses (AORN), and that staff were compliant with the facility's policy.

During interview of Staff B on 07/31/2025 at 9:19AM, Staff B confirmed that after reading the facility P&P for surgical attire, the OR staff with exposed earrings and the uncovered beard were not in compliance with the facility policy.