Joan Rivers’ death was precipitated by a series of serious mistakes at Yorkville Endoscopy, where she was undergoing a routine outpatient operation.

Joan Rivers Death Report

The Centers for Medicare & Medicaid Services released a report on Monday detailing all of the ways in which the Manhattan clinic failed to provide Rivers with adequate care. Among the errors noted were failing to notice deteriorating vital signs and failing to determine Rivers’ weight prior to administering the highly dangerous sedative Propofol, reported CNN.

Other causes for concern were the failure to document the dose of Propofol, failure to get River’s consent for all of the procedures and failure to only let those certified to practice medicine at the clinic perform a procedure. Appearing to confirm rumors about ENT doctor to the stars Gwen Korovin’s surgery selfie, the report also notes that Yorkville did not abide by its own cell phone policy.

Yorkville Responds To Joan Rivers' Death

After the report was made public, Yorkville Endoscopy released a lengthy statement in which it claims to have been cooperative throughout the investigation and has already taken steps to improve.

"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 statement reads. “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.

Melissa Rivers Taking Legal Action?

Melissa Rivers, Joan Rivers’ sole surviving child, has also been made aware of the report. Her lawyers, Jeffrey B. Bloom and Ben Rubinowitz, have released a statement on her behalf, indicating that she might soon be taking legal action against Yorkville.

"Our client, Melissa Rivers, is terribly disappointed to learn of the multiple failings on the part of medical personnel and the clinic as evidenced by the CMS report," Bloom and Rubinowitz’s statement read. "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."

Rivers underwent the ill-fated operations at Yorkville on Aug. 28. On Sept. 4, Rivers died at the age of 81 after she was removed from life support.