The state Health Department sent teams of inspectors to University Hospital in Newark after an anonymous "concerned employee" reported a bacterial outbreak in the neonatal intensive care unit at the Newark facility, Health Commissioner Shereef Elnahal confirmed Friday.

Four infants contracted the Acinetobacter baumannii bacteria, a hospital-acquired infection, in September. One of the babies was transferred to another hospital and later died, but the cause of death has not yet been determined, Elnahal said.

The three other infants responded to treatment, and there has not been any reported infections in three weeks, said University Hospital's Chief Medical Officer Larry Ramunno.

Responding to the Oct. 1 tip, state surveyors found numerous infection control deficiencies involving hand-washing, wearing gloves and keeping surfaces clean and disinfected, Elnahal said.

Elnahal said he found it "troubling" hospital executives did not report the outbreak, defined as a number of cases that exceed the norm for a health care facility.

"But the more troubling issue is the lack of infection control standards in that ICU. What my surveyors found was unacceptable," he said.

The hospital must hire a full-time certified infection control practitioner consultant by no later than Tuesday, according to the plan of correction ordered by the health department.

The state's only public hospital -- also the largest provider of "charity care" for uninsured patients -- University been under intense scrutiny this year. The hospital received a failing grade from the national Leapfrog Group safety report card, scoring poorly in areas of infection control.

The failing grade was one of the reasons the state appointed Judith M. Persichilli, the former CEO of the national hospital chain, Catholic Healthcare East, to monitor and assess the hospital's financial stability and quality.

On Friday, Persichilli and Ramunno said there is a concerted effort underway to make consistent hand-washing and other infection control strategies second nature among University's 3,600 employees.

"It's been all about behavioral change and building the will and culture since I landed in mid-June," said Ramunno, who had been recruited from the Johns Hopkins-owned Sibley Memorial Hospital in Washington D.C. "We're starting to see some movement, but we have to keep pushing it."

The changes now sought by the state were already underway, Ramunno said.

"Everything on the state's list is something we are working on. Was it all implemented? No, but we'll be using this as a stimulus to speed the changes that have to happen," he said.

Rumanno has the confidence of Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, a research and advocacy organization that promotes the Leapfrog safety group.

Schwimmer called the outbreak "heartbreaking" and demonstrates "the human toll of not taking safety and infection control as seriously as you need to, and why we need to be vigilant." She said she has met with Ramunno, and "I felt like he understood the seriousness of the situation and the enormous task in front of him."

The infection is not a threat to other patients in the hospital or in the community, according to medical experts. It is almost exclusively found in hospital intensive care units, and poses a risk to only the most immune-compromised patients, said Infectious Disease specialist Margaret Fisher, a member of disaster preparedness advisory council for the American Academy of Pediatrics.

Acinetobacter baumannii "is not usually the cause of death, but it's usually a contributor," Fisher said. "These babies are just so fragile and require so much technology that they are on the edge of survival. This (infection) tips them over."

There are other infants in the NICU, but there is no plan to transfer them to another hospital, Elnahal said. "Any transport poses a risk to such critically ill patients," and could spread the infection to another hospital, he said.

The outbreak at University Hospital is unrelated to the 23 confirmed cases of adenovirus in pediatric residents at the Wanaque Center for Nursing and Rehabilitation in Haskell. Eight children have died, according to the health department.

Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio. Find NJ.com Politics on Facebook.