Major mistakes by medical professionals in the death of Joan Rivers

Federal agency claims major violations by clinic that treated Joan Rivers

(CNN) -- The Manhattan clinic that treated comedian Joan Rivers before her death made a number of serious mistakes, including failing to identify deteriorating vital signs, and providing timely intervention, according to a report released Monday.
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.


Among the major errors CMS found the clinic committed are:
-- 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).