In just a few weeks late last year, 11 children with physical and developmental disabilities died in an adenovirus outbreak at the Wanaque Center for Nursing and Rehabilitation in New Jersey.
Many of the kids at Wanaque liked to play patty cake, listen to music and hold their stuffed animals. Although many couldn’t speak, they’d respond with giggles and smiles when they heard songs they liked or saw nurses who they recognized. They died in part because of negligence and significant lapses in care, according to a report by federal regulators with the Centers for Medicare and Medicaid Services, which fined the facility $600,000 last week.
The regulators’ research, published in an extensive, 114-page report last December, argues that the 11 deaths were the result of unhygienic cleaning and food preparation practices, negligent care of the kids and a disorganized system of leadership. The adenovirus is a particularly contagious, flu-like virus that can cause respiratory illnesses like pneumonia and bronchitis. One doctor at the center underestimated the virus’ capacity to affect patients and, at the time, questioned if it would even spread.
Lawyers for the facility said that the report, which HuffPost reviewed in full, was “riddled with factual inaccuracies” and that Wanaque plans on appealing the fine. CMS told HuffPost that it stands by its findings.
No one has been charged with a crime or lost their medical license over the deaths.
The lack of national outcry over the deaths of 11 children is disappointing but not surprising, Hector Ramirez, a disability rights activist in California, told HuffPost.
“If it was 10 able-bodied kids that died in, say, a school, our community would be up in arms,” Ramirez said on Tuesday.
“We would have a vigil. We would demand an explanation.”
In October of 2018, patients in the pediatric ventilator unit at Wanaque began to show symptoms of adenovirus, including high fevers. CMS reports that the haphazardly organized staff ― including a pediatric medical director who says he was never given a job description ― failed to implement “an adequate Infection Prevention and Control Program” and to “provide timely interventions and care.”
The report shows that patients who began showing symptoms weren’t taken to the hospital right away ― many weren’t hospitalized for up to a week, despite staff knowing there was a viral outbreak.
There was a policy of keeping beds at the facility filled as long as possible so that Wanaque didn’t lose its Medicaid funding, two anonymous employees told a local New Jersey Advance Media reporter.
In a December New Jersey Senate Health Committee hearing about the outbreak, a former employee echoed this.
“In recent years, I witnessed a change in how quickly the facility will send a patient to the hospital if they become ill,” Sherry McGhie, who worked at Wanaque for 27 years before leaving in September 2018, said at the hearing.
“It is well known among staff that a major priority is to keep the beds full.”
When staff notified one mother of her young daughter’s high fever on Oct. 3, for example, she asked them to transfer her child to the nearest hospital, but a doctor would not approve the move for another two days. That little girl died on Oct. 8, three weeks after her fourth birthday.
But the center didn’t just delay taking the patients to the hospital.
It’s likely that the poor hygiene practices helped the adenovirus spread. In their investigation, CMS staff members observed dirty refrigerators, juice pitchers, ceiling fans and sprinklers; they witnessed kitchen staff handle food, clean utensils and clean dishes with unsanitized hands and dirty gloves; patients were fed expired food or frozen food that had been sitting out in room temperatures.
The staff was reportedly disorganized, too, and the pediatric medical director was largely absent from the planning and during the response to the virus. CMS called this a “failure to designate specific responsibilities of oversight.”
If it was 10 able-bodied kids that died in, say, a school, our community would be up in arms.
Hector Ramirez, disability rights activist
With no specific roles allocated in the outbreak crisis, patient needs went unmet.
“I have not participated in the surveillance of infection control,” Pediatric Medical Director Maged Ghaly said in an interview with CMS during the investigation.
“I have never been shown the Infection Control report … No one at the facility has given me the regulations regarding the medical director, and I have never read them. I didn’t understand what medical director meant.”
Ghaly also openly acknowledged that he underestimated warnings from the New Jersey state health department about planning for the outbreak.
“I thought the state was overreacting,” he said. “I said ‘How is it going to spread?’ That was in October. I knew we had a problem after the fourth death.”
Just four months before the outbreak, Ghaly had made a $42,000 settlement with the New Jersey Comptroller’s office after he was found guilty of overcharging Medicaid patients.
The facility’s administrator and the regional director of clinical services reportedly wrote up an “Adenovirus Work Plan” but failed to share that plan with Ghaly.
“I realize now after looking at it [that] there should have been more about follow up to the recommendations,” the regional director said in November.
‘Their Trust Was Shattered’
Seven families altogether are planning to file lawsuits against the center, and two of those families lost children between the ages of 4 and 15 to the virus. The parents of affected kids weren’t even notified of the outbreak until mid-October, more than a week after the first death. A letter, dated Oct. 18, 2018, was sent to parents via regular mail.
“My clients that unfortunately lost their precious children to this outbreak are still immensely distraught and continue to grieve the loss of their children, who they entrusted to the Wanaque center,” Paul da Costa, who represents those seven families, told HuffPost.
In addition to the $600,000 fine, Wanaque was briefly barred from admitting new pediatric patients.
Now it’s back to business as usual.
“My clients entrusted their medically fragile children to this facility with the honest hope and belief that these kids would receive quality care and treatment, and ultimately that trust was betrayed,” da Costa said.
“They feel that their trust was shattered like a piece of glass.”
Some parents of patients who contracted the adenovirus had no choice but to send their kids back to Wanaque, and others are taking on the “herculean” task of trying to care for them at home, da Costa said.
“The children, as well as the adults, who live in places like Wanaque deserve so much more … I truly hope that we can come out of this tragedy with major changes to an industry which too long has put profit before quality care,” McGhie, the former Wanaque staff member, said at the state Senate hearing in December.
The owners of the Wanaque facility weren’t in attendance.