POCATELLO — Following an investigation into unclean surgical tools, the Idaho Department of Health and Welfare found that multiple surgical patients nearly came in contact with tissue fragments left on medical tools.
According to the results from a formal complaint filed with the U.S. Department of Health and Human Services, officials conducted an “unannounced on-site complaint investigation” at Portneuf Medical Center from Sept. 2 to 7, 2025.
The incident report states that multiple “deficiencies” were cited during a federal complaint to the Center for Medicare & Medicaid Services, including that Portneuf Medical Center “failed to ensure patients received care in a safe setting for 1 of 6 patients whose medical records were reviewed.”
The complaint discusses incidents involving two patients.
Portneuf Medical Center officials state that the issues have been fully resolved and that they quickly identified the problem, initiating an extensive internal investigation almost immediately after the issue was discovered.
The first patient
The first patient was a 61-year-old woman scheduled to receive a lumbar fusion surgery on Aug. 20.
In notes about the surgery, a physician who is not identified reportedly states, “While preparing to perform discectomy, my scrub tech notified me that there was biological material (tissue fragment) within the trials (surgical instrument). Therefore, back table was contaminated and we elected to abort the procedure and send the materials back to central processing for appropriate cleansing and sterilization.”
The notes then say the physician spoke with the anesthesiologist, who is also not identified.
“The director of anesthesiologist (sic) who felt that (the patient) would be fine in the lateral position, so I packed the wound with betadine-soaked 4x4s and placed drapes over the wound,” the notes stated.
The medical professional “then left the room and then came back once the instruments were prepared. … There were no complications.”
However, the incident report states that there could have been complications.
“There was nothing documented regarding whether the risks of keeping the patient under anesthesia for several extra hours outweighed the benefits,” the report states.
According to the report, the Director of Perioperative Services stated that they were aware the patient would be under anesthesia for an additional three hours as the surgical instruments were properly cleaned.
Another document reportedly showed that the patient had three significant drops in blood pressure from the time the anesthesia was started at 7:04 a.m., and the time it ended at 2:42 p.m.
The patient’s Certified Registered Nurse Anesthetist (CRNA) was interviewed on Sept. 4, where he stated that when they flipped the patient to the prone (facedown) position, he “could not obtain a blood pressure from her arterial line or any of her 4 limbs.”
He then said he gave her medication to raise her blood pressure, which was successful. The CRNA reportedly voiced concern about the “significant presser support” that the patient needed, and about continuing the surgery. At that point, the incident report says they decided to abort the case.
When asked what the benefit was to keeping the patient under anesthesia while the dirty surgical instruments were cleaned, the CRNA responded there was “no real benefit and keeping her asleep was not preferred.”
The CRNA allegedly also said he was “unsure if it was safe to close her as the incision had already been made.”
According to the incident report, the patient was not able to have the surgery that day. It was rescheduled for a week later, and she stayed in the hospital for 11 days.
“It was unclear if the prolonged anesthesia time while waiting on the surgical instruments was beneficial to patient,” says the incident report.
The second patient
The incident report says another patient was also affected by the unclean surgical tools.
During the investigation into the allegations, the hospital reportedly provided a list of all instances of Immediate Use Steam Sterilization (IUSS) over the past year.
According to The Association for Professionals in Infection Control and Epidemiology, IUSS is a “steam sterilization cycle where unwrapped medical instruments are subjected to an abbreviated steam exposure time and then used promptly after cycle completion without being stored.”
One entry from June stated “the rep brought 1 tray (instrument tray) and there wasn’t enough time between cases to process (instruments) per standard protocol.”
On June 16, a 68-year-old man reportedly underwent shoulder surgery and was reportedly “moved into the OR while the surgical instruments intended for his procedure had not yet completed sterile processing.”
According to the report, the “narrative states this was done to “appease” the physician, who was described as being on a “war path.”
The sterile processing manager was interviewed on Sept. 3, and said the dirty instrument was put through IUSS “based on the physician’s insistence, who did not want to disrupt his surgical schedule.”
The Vice President of Quality was also interviewed about this incident, and confirmed that the Chief Medical Officer had spoken to the physician about the misuse of IUSS, “emphasizing that it is intended for emergencies – not for convenience.”
When asked for documentation of re-education or corrective action, Portneuf Medical Center provided none, according to the report.
“The hospital failed to appropriately document re-education or retraining for the physician ad permitted the use of IUSS for convenience,” the report says. “This failure to enforce infection control standards and staff accountability placed future patients at risk for surgical site infections.”
Dirty tools being left dry
On Sept. 2, investigators reportedly observed dirty instruments being cleaned in the decontamination room, and the sterile processing technician was observed “creating the incorrect concentration of enzymatic cleaner to water.
On this same day, investigators said, a cart full of used surgical instruments waiting to be cleaned were “visibly soiled with dry blood.” According to the incident report, “they were observed with the sterile processing technician, who agreed they were not kept moist.”
“The hospital failed to ensure surgical instruments were kept moist between use in the OR and decontamination,” the incident report says.
‘A white substance’
On Sept 7, the director of quality was interviewed and “confirmed there were no documented benefits to keeping patient under anesthesia while the surgical instruments were reprocessed.”
The incident report for the patient continues, saying it was also “unclear why (the) patient’s physician documented she “tolerated the procedure well” and “there were no complications” when the procedure had to be aborted prior to completion due to extreme hypotension” before concluding that “the hospital failed to ensure patients received care in a safe setting.”
The report also states that the “facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection.”
On Sept. 2, during a tour of the sterile processing area, it was reportedly “noted the commercial cart washer, located inside an area referred to as “prep and pack” was observed with a white substance accumulated on the front of the doors running from the top of the doors to the bottom in several different columns.
A sterile processing staff member was asked about the white substance and reportedly stated it was “difficult to clean” and and the vendor was the one who maintained the cart washer.
Investigators tried to obtain a cleaning log or schedule but were told it was “not available.”
“It was unclear when or how the cart washer was cleaned,” the report states.
The director of compliance confirmed that the cart washer should be regularly cleaned and that a cleaning schedule would be developed going forward.
Findings
“Due to there being instances of bioburden on supposedly clean and sterile surgical instruments, the allegation was substantiated,” the findings report from the Idaho Department of Health and Welfare states. “However, due to the extensive action plan, no deficiencies relation to the allegation were cited.”
Essentially, because he hospital had already remedied the situation, there were no remaining issues that needed to be addressed.
The findings state that upon noticing the dirty instruments not being properly cleaned, and an increase in surgical site infections, “the Quality Management Department and infection control officer conducted an extensive investigation in to the incidents.”
“Through the internal investigation, which included record review, interview, and observation, they discovered the cause of the problem was a breakdown in the reprocessing responsibilities between the vendor surgical trays (instruments not owned by the hospital) and the SPD,” the findings state. “There was a lack of training to the Sterile Processing Department (SPD) on how to reprocess vendor trays, which contained instruments the staff were not familiar with and did not know how to clean properly.”
The findings say the vendors had access to the sterile processing area where they were leaving trays, and SPD did not know which trays had been pre-cleaned.
At the conclusion of the investigation, the findings include remediation plants to correct the problem such as revoking the vendor’s access to the Sterile Processing Department and “implementing a ‘hard stop’ where if staff were not familiar with instruments, they would not reprocess them.”
Hospital responds
EastIdahoNews.com reached out to Portneuf Medical Center for a comment on the allegations and findings, and we were sent the following statement:
“The safety and well-being of our patients is always our highest priority. Earlier this year, we self-identified an isolated issue with reprocessing certain specialized surgical instruments provided by an outside vendor. We immediately launched a thorough review and engaged an independent third-party expert to evaluate and strengthen our protocols. We moved quickly to retrain staff and add safeguards to prevent this from happening again, including implementing additional requirements for vendors. Recent state and accreditation surveys have confirmed the issue was successfully addressed. We proactively reached out to the small number of individuals whose procedures were affected, and all concerns related to this matter have been fully resolved.”
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