The clinic where Joan Rivers had a fatal routine surgery "failed to identify deteriorating vital signs and provide timely intervention," an investigation by the Department of Health and Human Services Center for Medicare and Medicaid Services has revealed.
Yorkville Endoscopy also failed to properly document how much of the sedative Propofol was used, and the report confirms that people in the room photographed Joan with a cell phone while she was sedated, according to ABC News.
Rivers, 81, died on Sept. 4, one week after undergoing an outpatient throat procedure at the clinic to treat voice changes and acid reflux. During surgery, Rivers stopped breathing and went into cardiac arrest. Last month, the New York City Office of Chief Medical Examiner ruled Joan ultimately died of a lack of oxygen to her brain.
"The cause of Ms. Rivers's death is anoxic encephalopathy due to hypoxic arrest during laryngoscopy and upper gastrointestinal endoscopy with Propofol sedation for evaluation of voice changes and gastroesophageal reflux disease. The manner of death is therapeutic complication," the OCME said in a statement. "The classification of a death as a therapeutic complication means that the death resulted from a predictable complication of medical therapy."
Following the comedian's death, the New York State Health Department launched a routine investigation of Yorkville Endoscopy, only to find lapses in four categories necessary for accreditation: governing body and management, surgical services, medical staff, and patient rights.
In a statement regarding Monday's findings, attorneys for Melissa Rivers said in a statement: “Our client, Melissa Rivers, is terribly disappointed to learn of the multiple failings on the part of the medical personnel and the clinic as evidenced by the CMS report. As any of us would be, Ms. Rivers is outraged by the misconduct and mismanagement now shown to have occurred before, during and after the procedure. Moving forward, Ms. Rivers will direct her efforts towards ensuring that what happened to her mother will not occur again with any other patient.”
Yorkville Endoscopy issued the following statement regarding the report as well:
"From the outset of the August 28th incident described in the CMS Report, Yorkville has been fully cooperative and collaborative with all regulatory and accreditation agencies. In response to the statement of deficiencies, Yorkville immediately submitted and implemented a plan of correction that addressed all issues raised. The regulatory agencies are currently reviewing the corrective plan of action and have been in regular contact with Yorkville. In addition, the physicians involved in the direct care and treatment referenced in the report no longer practice or provide services at Yorkville. Yorkville will continue its commitment to complying with all standards and accreditation requirements."
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