The report, issued by the Centers for Medicare & Medicaid Services (CMS), a federal agency, did not mention Rivers by name, but referred an 81-year-old female, or Patient #1.
The description of that patient and the procedures she underwent match what's known about Rivers, including her age and the date of her appointment. CMS declined to say whether the patient referenced in the report is Rivers.
The famed 81-year-old entertainer died September 4, a week after an appointment at Manhattan's Yorkville Endoscopy clinic.
-- Failing to identify deteriorating vital signs and provide timely intervention;
-- Failing to record Rivers' weight, prior to the administration of medication for sedation;
-- Failing to consistently document the dose of Propofol, a sedative, administered;
-- Failing to get Rivers' informed consent for each procedure performed;
-- Failing to ensure that she was cared for only by physicians granted privilege in accordance with the clinic's bylaws;
-- And finally, failing to abide by its own cell phone policy (the report found that a photograph was taken of a surgeon and Rivers while she was under sedation).
Yorkville Endoscopy released a statement in response to the report, saying it has been cooperative and already taken steps to correct the situation.
"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," it said.
Rivers' appointment at the clinic was on August 28. Paramedics rushed Rivers from the clinic to New York's Mount Sinai Hospital a mile away, where she was kept on life support until she died a week later.
Her daughter, Melissa, "is terribly disappointed to learn of the multiple failings on the part of medical personnel and the clinic as evidenced by the CMS report," according to a statement from her attorneys.
"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," it read.
The New York medical examiner ruled last month that Rivers died of "therapeutic complications" during a procedure to evaluate her "voice changes" and stomach reflux.