Li­cense re­voked af­ter 14-year-old boy’s death in May

Re­port: Firely staff mem­bers ignored alarm for nearly 20 min­utes as oxy­gen level fell

The Morning Call - - FRONT PAGE - By Pe­ter Hall

AL­LEN­TOWN — Two staff mem­bers at an Al­len­town home for se­verely dis­abled chil­dren ignored an alarm that sounded for nearly 20 min­utes as a 14-year-old boy’s oxy­gen level dropped to dangerous lev­els, ac­cord­ing to a state re­port that led to the fa­cil­ity’s li­cense be­ing re­voked.

The child, iden­ti­fied by Le­high County Coro­ner Eric Min­nich as Gio­vanni Almod­ovar-Rios, died May 16 af­ter go­ing into car­diac ar­rest. He was rushed from the Firely Pe­di­atric Ser­vices Home for Kids in south Al­len­town to Le­high Val­ley Hospi­tal-Cedar Crest, where he was pro­nounced dead. The coro­ner’s of­fice and the Al­len­town Po­lice De­part­ment Spe­cial Vic­tims Unit are in­ves­ti­gat­ing, Min­nich said.

The in­ves­ti­ga­tions didn’t be­gin un­til June be­cause Gio­vanni’s death was ini­tially de­ter­mined to be due to nat­u­ral causes, Min­nich said. In­for­ma­tion came to light later that trig­gered the in­ves­ti­ga­tion,

said Min­nich, who de­clined to say specif­i­cally what led au­thor­i­ties to in­ves­ti­gate.

A Pennsylvan­ia De­part­ment of Hu­man Ser­vices in­spec­tion re­port sent to Firely Pe­di­atric Ser­vices on July 23 said the fa­cil­ity failed to re­port the death and that DHS and its Of­fice of Chil­dren, Youth and Fam­i­lies learned of the in­ci­dent dur­ing an unan­nounced visit. The re­port says the death was not re­ported to Child­line, the state child abuse hotline, un­til June 7. State reg­u­la­tions re­quire deaths in child res­i­den­tial fa­cil­i­ties to be re­ported to DHS ver­bally within 12 hours and in writ­ing within 24 hours.

The re­port also says it was the sec­ond time in about a year that staff at the res­i­den­tial fa­cil­ity on Sun­shine Road ignored a warn­ing from med­i­cal equip­ment, al­low­ing a dis­abled child’s heart to stop beat­ing. An in­ci­dent on April 4, 2018, which oc­curred when a child’s breath­ing tube be­came de­tached from a ven­ti­la­tor, led to a cor­rec­tive plan of ac­tion in which nurs­ing staff were in­structed to “treat each alarm as if it is real.”

DHS no­ti­fied Mont­gomery County-based Firely Pe­di­atric Ser­vices in July that it was re­vok­ing the li­cense for the com­pany’s Al­len­town fa­cil­ity for its fail­ure to com­ply with the state Hu­man Ser­vices Code; gross in­com­pe­tence, neg­li­gence or mis­con­duct; and mis­treat­ing or abus­ing peo­ple cared for in the fa­cil­ity.

Marty Firely, pres­i­dent of the fam­ily-owned com­pany, said this week that he is ap­peal­ing the DHS de­ci­sion but plans to close the 16-bed fa­cil­ity and move most of its re­main­ing 14 res­i­dents to other fa­cil­i­ties the com­pany op­er­ates this week.

“We ac­knowl­edge that some­thing hor­ri­ble hap­pened and we don’t want any­thing like that to hap­pen again, but we’re go­ing to work with the state to get our record clean,” Firely said.

It was not his com­pany’s re­spon­si­bil­ity, he said, to re­port the death be­cause it oc­curred af­ter the child left the fa­cil­ity.

“There is no way we could have re­ported any­thing once that child left our care,” he said.

A spokes­woman for Le­high Val­ley Health Net­work said the hospi­tal fulfilled its obli­ga­tion by re­port­ing the death to the coro­ner’s of­fice.

Gio­vanni had cere­bral palsy, which causes mus­cle weak­ness and im­paired mo­tor skills. His mother, Glenda Rios, moved with Gio­vanni from Puerto Rico in search of bet­ter med­i­cal care for her son, said Gina Figueroa, an Al­len­town School Dis­trict nurse who cared for the boy while he was in school. Figueroa also started a GoFundMe cam­paign to pay for Gio­vanni’s fu­neral ex­penses.

Figueroa said Gio­vanni was liv­ing at the Firely fa­cil­ity while his mother worked to se­cure sta­ble hous­ing.

“That poor woman moved here from Puerto Rico to give her son a bet­ter chance at life,” Figueroa said. “All she wanted was to bring her baby home.”

Figueroa said Gio­vanni suf­fered res­pi­ra­tory prob­lems and had a tra­cheostomy where a breath­ing tube con­nected him to a ven­ti­la­tor. His mother was pre­par­ing her apart­ment with the ma­chines Gio­vanni would need to live at home with her, Figueroa said.

Ac­cord­ing to the DHS re­port, se­cu­rity cam­era footage showed a staff mem­ber in and out of Gio­vanni’s room sev­eral times af­ter 5 a.m. the day he died. The staff mem­ber was in the room for about 11 min­utes be­fore calling a sec­ond staff mem­ber for help.

The sec­ond staff mem­ber was in an ad­join­ing room wear­ing ear­buds while an alarm was go­ing off on the boy’s pulse oxime­ter, which mea­sures the oxy­gen level in blood. The sec­ond staff mem­ber did not go into Gio­vanni’s room to answer the alarm, the re­port says.

Data from the pulse oxime­ter showed Gio­vanni’s oxy­gen lev­els had been drop­ping for about half an hour be­fore staff in­ter­vened. Staff failed to no­tice that he was in dis­tress and the alarm sounded for 18 1⁄2 min­utes be­fore they checked his well be­ing, the DHS re­port says.

Firely Pe­di­atric Ser­vices re­ported that the staff’s records con­flicted with the pulse oxime­ter re­port and se­cu­rity cam­era footage, the DHS re­port says.

The DHS re­port states that the Firely Pe­di­atric Ser­vices staff’s fail­ure to re­spond to the pulse oxime­ter alarm di­rectly re­sulted in the child’s death. Both staff mem­bers were fired for will­ful mis­con­duct, the re­port says.

It also states that the fail­ure to re­spond to the alarm was a vi­o­la­tion of the pol­icy DHS ap­proved af­ter the April 2018 in­ci­dent when an­other child came close to death.

The pol­icy re­quired that in ad­di­tion to treat­ing pulse oxime­ter alarms as if they are real, staff mem­bers are to as­sess a client’s color, breath­ing and pulse oxime­ter read­ings when an alarm sounds.

The in­spec­tion re­port de­scrib­ing the fail­ures that led to Gio­vanni’s death noted six other vi­o­la­tions in­clud­ing record-keep­ing prob­lems and a child who was con­fined to a room and left alone for more than an hour.

Firely said he dis­agrees with the DHS re­port but de­clined to dis­cuss the events lead­ing to Gio­vanni’s death.

“What­ever hap­pened at our fa­cil­ity, I can’t di­ag­nose,” he said.

Firely Pe­di­atric Ser­vices has nine fa­cil­i­ties. The Al­len­town fa­cil­ity opened about 12 years ago, Firely said.

“We’ve cared for a large num­ber of kids there very suc­cess­fully for a long time,” he said.

He ac­knowl­edged prob­lems with staff at the fa­cil­ity, in­clud­ing the April 2018 in­ci­dent, but said those in­volved had been re­trained.

“The only thing I can’t do is make some­one de­cide to do their job,” he said. “We pro­vide all the train­ing, all the knowl­edge, all the over­sight. I wish I had more re­course than to ter­mi­nate them.”

DHS records avail­able on­line in­di­cate in­spec­tions un­cov­ered other is­sues rang­ing from record-keep­ing er­rors to un­safe or un­san­i­tary con­di­tions on a dozen oc­ca­sions in the last decade.

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