N.J. surgery center that possibly exposed thousands to HIV had rusty equipment, report says

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By Kalhan Rosenblatt

The New Jersey surgery center that may have exposed more than 3,700 patients to HIV and hepatitis used rusty equipment and had soiled bed sheets, according to a report from the state’s department of health.

HealthPlus Surgery Center in Saddle Brook, New Jersey, was closed on Sept. 7 after the New Jersey Department of Health discovered multiple violations of sterilization and sanitation requirements, according to a citation summary sheet made public on Friday. The state allowed HealthPlus Surgery Center to reopen on Sept. 28.

But before HealthPlus was cleared to reopen, it was forced to correct a number of violations, including improper storage of medications, issues with personnel requirements, and failure to adequately sterilize equipment.

The citation sheet described sterilized instruments as containing “rust like stains.” Staff told the department of health surveyor that if rust is visible, a nurse would make the decision as to whether or not it should be used in a procedure, according to the report.

The report also detailed medical staff who failed to cover their beards and facial hair during procedures. Another violation noted a stretcher reserved to transport a patient contained a “red wet stain,” which was improperly cleaned even after the surveyor asked if it would be changed, according to the report.

Since the discovery of the improper sterilization procedures, HealthPlus has fired two employees, according to the facility’s attorney Mark Manigan.

“Leading consultants to provide procedural overhaul and to train staff, both existing and new, were immediately engaged, and we are confident that the issues raised by the department have been addressed,” Manigan said at a press conference on Saturday.

Since the violations were discovered, HealthPlus said it hired new staff members, improved infection control, conducted training for its new sterile-processing staff, and cleaned and repaired all medical equipment.

Earlier this month, patients who were seen at the facility between Jan. 1 and Sept. 7 and may have been infected during their time at the surgery center were contacted by HealthPlus via a letter distributed by the department of health.

Manigan told NBC News on Wednesday that the delay between the discovery of the violations and contacting patients was due to the center consulting with health officials “with respect to what protocols and policies would dictate reviewing records to find the appropriate universe of patients and extrication of patients not affected.”

On Saturday, Manigan said the first 186 people to be tested had no infections, but added one person has come back with positive preliminary results for chronic hepatitis. Manigan said the preliminary results indicate “a condition prior to patient being treated” at HealthPlus.

“We are aware of patients with pre-existing conditions such as HIV, hepatitis B and hepatitis C. We expect to find more as the process continues. The department also recognizes that within this population there could be undiagnosed cases of pre-existing conditions and, on the basis of what we know and what we don’t know, the appropriate response is to test,” Manigan said.

Manigan said during the press conference that it could take one to two weeks for patients to get their results, and that if someone tests positive, the New Jersey Department of Health would investigate whether the disease was pre-existing or if it had been contracted by HealthPlus.

One former HealthPlus patient still waiting on her results Saturday was Kristin Debenedictis, 37, of Rochelle Park, New Jersey.

Debenedictis was treated for a herniated disk at HealthPlus Surgery Center in April and July following a car accident in January.

When she received the letter from HealthPlus informing her that she had potentially be exposed to HIV and hepatitis, she was shocked.

“To let us be in the dark from January up until the holidays this December, it’s extremely horrible,” Debenedictis told NBC News on Wednesday. “Shame on you, HealthPlus.”

Debenedictis said she was tested on Christmas Eve. On Saturday her lawyer Sanford Rubenstein told NBC News that his client was still waiting on her results.