In the midst of the virus outbreak that swept through the pediatric ventilator unit of a Wanaque nursing home, state inspectors found two empty rooms that had not been disinfected for days after their residents had been hospitalized and died.

They found 15 occupied rooms with cleanliness problems, including one where a power cord ran through a large puddle of feeding formula on the floor near a bed where a patient lay.

And they talked to a disabled patient who was wearing two urine-soaked diapers and said he or she had last been changed the night before. The patient, an adult, had asked a nurse's aide to change the diaper at 7:30 a.m., the patient told inspectors, but was told to eat breakfast instead.

These were among the conditions that state inspectors observed at the Wanaque Center for Nursing and Rehabilitation on Oct. 30 and Nov. 14, several weeks into an adenovirus outbreak that ultimately sickened 36 severely disabled children, 11 of whom died. A report of the inspection was provided to the facility on Friday and released by the state Health Department on Monday.

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“Nothing in the report identifies systemic deficiencies in policies or procedures,” Rowena Bautista, the Wanaque center’s administrator, said in a statement released by the communications consultant for Paul Fishman, the center’s attorney. “There is no suggestion that the deficiencies identified contributed to the viral outbreak. We already have addressed all issues raised by the Health Department and continue to cooperate.”

But state Sen. Joseph Vitale, chairman of the Senate Health Committee, said the conditions described in the report were “a disgrace.”

"To be in an environment that’s that filthy, and it appears some employees were not responsive to patients’ needs — it’s not acceptable,” he said. “It’s awful.” He questioned how employees could allow such conditions to persist, and said the onus was on the owners to replace broken or dilapidated equipment.

“These are people who don’t have a voice for themselves,” Vitale said of the patients at the Wanaque center. “It’s inexcusable.”

Adenovirus typically causes cold- and flu-like symptoms in healthy people, but it can be devastating to medically fragile children and others with compromised immune systems.

Uncleaned rooms, urine-soaked diapers

The report detailed the experience of one adult patient, whose age and gender were not specified, and who was living at the facility because of an unspecified head injury, muscle weakness and a urinary tract infection. This patient was able to be interviewed by the inspector, who had checked the patient's “incontinent brief,” or diaper and found there were actually two briefs that were “saturated with yellow urine.”

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The nurse’s aide assigned to the patient's care agreed that she had been asked to change the diaper and had told the patient to eat breakfast first. She acknowledged to inspectors that she hadn’t checked for wetness during her morning rounds.

The report also described two empty rooms that had gone days without “terminal cleaning” — a thorough cleaning with disinfectant that is usually a standard practice within 24 hours of a patient’s discharge.

One room had been empty for 10 days when inspectors noticed the open door on Oct. 30. They noted personal items on a crib, an open bottle of saline solution and trash in a garbage bin. Both of the patients who had occupied it had died after being transferred to hospitals.

The door of the other room was closed. It had been empty for two days, the report said.

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Housekeeping managers told inspectors they didn’t know the rooms needed terminal cleaning or that the patients had been discharged. The assistant director of nursing could not explain it, the report said. But the administrator explained to the inspector that “the delay in terminal cleaning … was because the family had not come to pick up the resident’s personal items,” the report said.

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Meanwhile, in 15 of 27 occupied rooms the inspectors visited, they noted bed frames, ventilator carts and heating units that had “accumulated rust-like substance.” The upholstery of medical recliners known as geri chairs was torn and cracked, with foam and metal showing through in places. The center lacked a plan for preventive maintenance, the report said.

The report also noted that one of the patients hadn’t been screened for physical therapy and occupational therapy in a timely manner.

The physical therapist explained that she screened the patient on the day of the inspection and hadn’t done it within a week of the patient’s admission “because she was distracted by what was going on at the facility.”

Previous inspections

It was not the first time inspectors had visited Wanaque, a 227-bed nursing home with a unit for more than 60 ventilator-dependent children.

An inspection team already had made one visit to the facility — on Oct. 21 — and a member of the communicable-disease division of the state Health Department was stationed at the center full time when the additional inspection visits that were the subject of the report were made.

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Immediately after the Nov. 14 visit, however, the state Health Commissioner, Dr. Shereef Elnahal, declared that the center posed “an imminent and serious risk of harm” to its residents. He ordered it to halt admissions and to hire specialists in infection control and infectious diseases to help bring the outbreak under control.

Since then, no additional residents have become sick with adenovirus or died of it, according to the state Health Department. The consultants remain on site, and admissions to the pediatric ventilator unit have not resumed.

But questions remain about whether the center acted properly and whether the deaths of so many children, whose compromised immune systems made them particularly vulnerable to this strain of the virus, were preventable.

Paul da Costa, an attorney representing the families of six of the Wanaque center’s residents, said the report echoed the conditions his clients had described, especially when it came to the use of double diapers. Two of the families he represents had children who died of adenovirus.

“These new reports unfortunately seem to be consistent with what my clients believe to have been negligent conduct on the part of the facility and its employees,” he said. “My clients look forward to searching for further information and the truth through litigation.”

The center’s owners, Eugene Ehrenfeld and Daniel Bruckstein, did not attend a state Senate Health Committee hearing about the outbreak on Dec. 3 and have never spoken publicly about it. They have retained Fishman, a former U.S. attorney in Newark, to represent them.

While poor infection control remains the root cause of the virus’s spread, some have alleged that the center delayed transferring sick children to the hospital for economic reasons. The daily reimbursement of $518 per child from New Jersey Medicaid ceased once the patients it insured went to the hospital. Lawmakers whose district includes Wanaque have asked the New Jersey attorney general to launch a criminal investigation.

Others have pointed to the inability of the center to separate, or "cohort," patients according to their disease status. Only when enough rooms had become vacant — due to deaths and hospitalizations — were the patients separated into “red,” “yellow” and “green” zones, depending on whether they had a laboratory-confirmed diagnosis of adenovirus, symptoms without confirmation, or no symptoms of the disease.

Email: washburn@northjersey.com

This story has been updated to reflect the following correction: The patient whom inspectors found wearing two urine-soaked diapers was an adult, not a child.