Report Details Lapses In Care At Wanaque Where 9 Kids Died



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PASSAIC COUNTY, NJ — A new inspection report of the Wanaque Center for Nursing and Rehabilitation, where nine kids died in a viral outbreak, revealed lapses in hand-washing and infection control at a surprise inspection earlier this month.

In one instance on Oct. 21, after the onset of the outbreak, a licensed nurse touched a patient’s tracheotomy tube and a ventilator machine without gloves, the report stated. The nurse then left the room, opened a window in another resident’s room without washing her hands, and went to her medication cart, the inspection report said.

In another incident, a respiratory therapist put a gown and gloves on and put a breathing mask on a resident. She took her gloves and mask off and touched her hair without washing her hands. She then went to another resident’s room, attached a pulse monitor to their foot, left without washing her hands, and went to another resident’s room.

Inspectors said they observed a nursing assistant use the same gloves to remove a soiled diaper, respiratory tube, and a resident’s tracheotomy collar, the report said. Incidents of nurses failing to wash their hands for the required 20 seconds were also observed, according to the inspection report.

The deficiencies, “did not indicate substandard care was delivered,” according to standards outlined by the state Department of Health.

“Now that the report is finalized, certain findings raise questions about whether these general long-term care standards are optimal for this vulnerable population of medically fragile children,” said New Jersey Health Commissioner Dr. Shereef Elnahal.

New regulations requiring that long-term care facilities have an infection preventionist responsible for the facility’s infection prevention control program on-site begin Nov. 28.

“We also need to think about whether there is more we can do as healthcare leaders to protect immunocompromised children, such as those served at Wanaque Center,” Elnahal said.

State officials will visit four pediatric care facilities and a hospital next month to conduct training and assessments of infection control procedures after 26 people were sickened and nine died following the outbreak of the adenovirus at the Wanaque Center.

The team will visit University Hospital, Wanaque Center for Nursing & Rehabilitation in Haskell, Voorhees Pediatric Facility in Voorhees, and Children’s Specialized Hospital in Toms River and Mountainside.

Victims got sick between Sept. 26 and Oct. 22. Twenty-six kids and a staff member, who has since recovered, have become ill as part of the outbreak, state health officials said. Laboratory tests confirmed the 26th case.

Authorities confirmed the virus killed eight of the nine children, all of whom were “medically fragile” with compromised immune systems, state officials said. Many of the patients have lived at the facility “all or most of their lives” because of medical conditions.

The Department of Health was notified of the outbreak on Oct. 9. The state began monitoring the situation Oct. 10. State personnel will remain at the facility until the outbreak is over. The U.S. Center for Disease Control is assisting state officials and conducting lab tests related to the outbreak.

Read more: Families Would Be Notified Quickly Of Outbreaks If Bill Passes

The department needs four weeks without an additional case reported in order for the outbreak to be considered over.

Adenoviruses are typically a family of viruses that often cause mild illness, particularly in young children, though serious illness is less common. People with weakened immune systems, or existing respiratory or cardiac disease, are at higher risk of developing severe illness from an adenovirus infection, according to the Centers for Disease Control and Prevention.

Click here to read the inspection report.


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