State health inspectors initially blamed poor hygiene for an adenovirus outbreak that killed 11 kids at a Wanaque, N.J., nursing home and rehab center last fall, but a CMS report found the bigger problem was that the facility's leaders didn't respond fast enough when the outbreak hit, according to northjersey.com.
The report said the pediatric medical director of the Wanaque Center for Nursing and Rehabilitation was so disengaged in his role that he did not know how many children were infected or what his job entailed.
That physician, who is not named in the report, told inspectors he had been barely aware of the crisis.
"I knew we had a problem after the fourth death," he said, according to the report.
But it took five more weeks — and seven more deaths — before the outbreak was controlled.
These leadership deficiencies "contributed to the delay in identification and containment of [the] adenovirus outbreak, affecting 33 residents [and] one staff, and resulted in 11 pediatric resident deaths," the report said.
Adenoviruses usually only cause a cough, cold, conjunctivitis or urinary tract infection, but adenovirus 7, the strain that hit the facility, was particularly severe. And the children at Wanaque, who relied on breathing ventilators or tubes in their stomachs for nutrition, were especially vulnerable.
No new adenovirus cases have been reported at the center since Nov. 12, but the state is still blocking new admissions to the pediatric ventilator unit, pending approval of the center's recently submitted infection control plan.
The center's administrator, Rowena Bautista, challenged CMS' findings, calling them "unfounded allegations."
"We are infuriated that, after a cursory review, federal surveyors put together a report riddled with factual inaccuracies, disregard of medical judgment and blatant misstatements about how viruses spread," she said in a statement. "The center has appealed the report's findings, she said, "and will vigorously dispute the allegations."