When the news broke on Christmas Eve that a Bergen County surgery center might have exposed almost 4,000 patients to HIV and hepatitis B and C, there were scant details about what actually went wrong.
A state report released on Friday afternoon on HealthPlus Surgery Center in Saddle Brook shows what did: Staff regularly failed to wash their hands; I.V. bags and tubes were used on multiple patients; powerful opioids were handled recklessly; and the facility was relying on an infection control plan almost 10 years old.
The New Jersey Department of Health inspected the HealthPlus Surgery Center on Sept. 7 after receiving a complaint about the facility, and immediately shuttered it for three weeks. Earlier this month, HealthPlus sent letters to 3,778 patients who had procedures done at the facility between Jan. 1 and Sept. 7, urging them to get tested for HIV and hepatitis B and C.
Mark Manigan, a lawyer representing HealthPlus, said in an interview with NJ Advance Media on Friday that the surgery center believes a former employee filed the complaint. He added that two staffers had been fired from the facility but declined to identify them.
Manigan also declined to identify the facility’s current medical director, saying that “threats” had been made against HealthPlus’ personnel.
For-profit surgery centers like HealthPlus have been a source of ongoing controversy as they’ve gained in recent popularity, with critics charging that the push for profit leads to unsafe conditions in certain facilities. A USA Today investigation published in March detailed widespread problems found at for-profit surgery centers nationwide, including ones in New Jersey.
‘Rust-like stains’ and a bloody sheet
Among the most alarming findings in the state’s report: Operating rooms at the facility were not properly cleaned and disinfected between procedures, upping the chances of exposure to dangerous diseases. According to the report, surgical tools were sometimes discovered with “brown rust-like stains” just before use.
In one instance, a state inspector observed a stretcher in a hallway with a blood-stained sheet that wasn’t properly disinfected even after the inspector pointed out the problem to staffers.
Most troubling, a HealthPlus employee told a state inspector that “due to the high volume of procedures, surgical trays were not always allowed to dry in sterilizers before being used.”
What kind of volume was HealthPlus dealing with? Between Jan. 1 and Sept. 7 this year, 3,778 patients had procedures done at HealthPlus. That comes out to an average of more than 15 procedures per day at the facility, assuming that surgeons were operating seven-days-a-week with no closures for holidays.
Infection control wasn’t the only problem at HealthPlus. The Sept. 7 report paints a picture of possible opioid theft by HealthPlus employees. Multiple examples are listed in the report of large amounts of potent opioids like Fentanyl and Oxycodone going missing.
“Someone was either throwing out the medication, or it was being stolen,” Manigan said. “We believe that the problem has been resolved.”
The state also found that drugs which needed to be refrigerated were stored at room temperature.
The state found Healthplus’ most current infection control plan was dated 2010 and bore the previous name of the facility, Renaissance Surgery Center, which used the same building as and directly preceded HealthPlus.
In 2013, Renaissance was blasted by the state health department for poor infection control, employing workers who’d tested positive for tuberculosis, and for lacking basic sanitation items like soap and disposable hand towels at handwashing stations.
HealthPlus Surgery Center reopened on Sept. 28, a day after the state health department determined that it had corrected the deficiencies found in its Sept. 7 survey.
“We have made significant improvements to ensure our patients’ safety and good health,” said HealthPlus Administrator Betty McCabe in statement issued to media on Monday.
In addition to the firing of two employees, a new director of nursing has been hired, according to Manigan. Under the corrective plan, the new nursing director is responsible for all of the new policies.
HealthPlus is also required by the state to conduct quarterly infection control audits and sterilization audits every six months.
The state health department has said that the risk of infection is low, and the department is not aware of any illness as a result of the infection control issues at HealthPlus. Nonetheless, Those affected can call 1-888-507-0578 weekdays between 9 a.m. and 9 p.m. to schedule a test at Hudson Regional Hospital in Secaucus, or at and LabCorp locations in New Jersey or New York.
Read the state’s Sept. 7 report, the corrective plan submitted by HealthPlus and the state’s follow-up report below: