The Manhattan clinic where Joan Rivers went into hypoxic arrest during a medical procedure over the summer violated a number of federal Medicare regulations, including failing to intervene fast enough when her oxygen supply was cut off, a federal report has found.
The Centers for Medicare and Medicaid Services detailed the findings of its Sept. 5 survey of Yorkville Endoscopy on East 93rd Street in a report released Monday.
The CMS previously announced it plans to drop the clinic as a Medicare-accredited facility on Jan. 7, 2015, meaning Yorkville Endoscopy will no longer receive federal funds for services provided to Medicare and Medicaid beneficiaries. The clinic says it has submitted a plan of correction to try to avoid termination of the Medicare agreement. In the meantime, it remains fully Medicare-accredited.
It wasn't until Monday that the CMS detailed exactly how the clinic was found non-compliant with certain conditions for coverage.
State health officials conducted an unannounced survey of the clinic on Sept. 5 on behalf of the CMS, a day after Rivers died at a hospital after being taken off life support. Officials were looking specifically into the Aug. 28 procedure on Rivers, during which her oxygen supply was cut off and she went into hypoxic arrest, according to the medical examiner's office.
Among the findings of survey, according to the CMS report:
- The ear, nose and throat doctor who conducted the Aug. 28 procedure on Rivers was not a member of the medical staff at that clinic and did not have privileges at the facility.
- Doctors "failed to identify deteriorating vital signs and provide timely intervention" when Rivers' oxygen supply was cut off
- While resuscitation on Rivers began on 9:28 a.m., the ENT doctor continued to do another nasolaryngoscopy and kept a scope in her throat for a minute or two before removing it at 9:30 a.m.
- By 9:30 a.m., Rivers' blood pressure was 85/49 and there was no pulse. She was not resuscitated until 10 a.m.
- There was conflicting information as to when CPR began on Rivers.
Also, the survey found, doctors did not record Rivers' body weight as part of the pre-assessment prior to the sedation; medical records lacked informed consent for all of the procedures performed on her; and conflicting information was recorded as to how much of the anesthetic propofol was given to Rivers.
Additionally, during the second laryngoscopy performed by the ENT surgeon, the Yorkville endoscopist proceeded to take pictures of the surgeon and Rivers with his cellphone, the CMS report stated: "Staff #1 said maybe Patient #1 would like to see this in the recovery area."
The report does not identify Rivers by name and instead only refers to a Patient No. 1, an "81-year-old female," but the timeline of events and the date of death, noted as Sept. 4, matches up with Rivers.
Yorkville Endoscopy said it has been "fully cooperative and collaborative" with the CMS, and that it has submitted a plan of correction.
If the CMS reviews and accepts the plan, and the clinic passes another unannounced survey by officials before January, Yorkville Endoscopy may keep its Medicare funding.
"Yorkville has been and remains open and active and is fully accredited by an independent review organization," Yorkville said in its statement. "The staff and providers are focused on providing the highest quality and most advanced care possible to its patients."
Yorkville Endoscopy is accredited by the American Association for Accreditation of Ambulatory Surgery Facilities, which is separate from CMS certification. The association has said it was investigating the facility's accreditation.
Rivers' daughter Melissa Rivers said in a statement through her lawyers Monday that she was "outraged by the misconduct and mismanagement now shown to have occurred before, during and after the procedure."
The medical examiner previously said Rivers suffered brain damage when her oxygen supply was cut off and classified the legendary comedian's death as a "therapeutic complication," meaning it resulted from a "predictable complication of medical therapy" -- or a known risk of the procedure.
According to the medical examiner, Rivers went into hypoxic arrest while she was undergoing a largyngoscopy, a routine medical procedure used to obtain a view of the vocal folds and the glottis, and an upper gastrointestinal endoscopy, which uses a flexible tube with a light to see the lining of the upper GI tract. She was being evaluated for voice changes and gastroesophageal reflux disease.