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

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.