Joan Rivers' Death: Report Says Clinic ‘Failed to Identify Deteriorating Vital Signs’

The Manhattan facility where Joan Rivers underwent a fatal medical procedure "failed to identify deteriorating vital signs and provide timely intervention," according to an investigation by the New York Department of Health and Human Services released on Monday.

Joan Rivers' Death: Report Says Clinic ‘Failed to Identify Deteriorating Vital Signs’

Rivers suffered brain damage due to lack of oxygen while undergoing a laryngoscopy and an upper gastrointestinal endoscopy at Yorkville Endoscopy on Aug. 28. She died September 4.

The Dept. of Health report, obtained by NBC News, indicates the clinic failed "to ensure that patient care services are provided in a manner that protects the health and safety of all patients” and failed to have a process in place regarding unauthorized personnel in the procedure room.

According to the investigation, an ear, nose and throat specialist "who was not a member of the medical staff and was not privileged at the facility" performed two different "nasolaryngoscopies," one before the endoscopy and one after it. The ENT surgeon was noted in Rivers' medical records as a referring physician, the report states.

There were also discrepancies as to how much propofol was administered to Rivers during the procedure.

In a statement Monday, Yorkville Endscopy said the clinic remains open and is still fully accredited.

"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."

Melissa Rivers has hired a New York personal injury law firm, who issued a statement on her behalf:

"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. 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."