It was a tragicomedy of errors.
In a blistering report released Monday, the feds ripped the Upper East Side clinic where comedian Joan Rivers went into cardiac arrest.
The report by the U.S. Department of Health and Human Services concluded that Yorkville Endoscopy “failed to ensure that patient care services are provided in a manner that protects the health and safety of all patients.”
But the biggest blunder cited in the report was that physicians in charge of Rivers’ care “failed to identify deteriorating vital signs and provide timely intervention during the procedure.”
Based on interviews with staff, a review of medical records and inspections of the E. 93rd St. facility, the report found that unauthorized personnel were allowed into the procedure room and staff failed to follow numerous safety protocols.
In documents released Monday, Rivers is identified simply as an 81-year-old patient who went the facility the morning of Aug. 28 and consented to a throat exam known as an esophagogastroduodenoscopy. The procedure involved using a thin scope with a light and camera at its tip to look inside the area between the throat and upper intestine.
Rivers’ medical history included chronic reflux disease, in which stomach acid went into her esophagus and caused mucous membrane damage.
The clinic’s gastroenterologist, Dr. Lawrence Cohen, was scheduled to do the procedure, but River’s brought along an ear, nose and throat specialist who took over.
While Rivers’ own specialist is not named in the report, she has been identified by the Daily News as Dr. Gwen Korovin.
Korovin, according to the report, performed a laryngoscopy and two nasolaryngoscopies, using a nasal intubation process. The procedures Korovin performed were not consented to by Rivers, who was knocked out during the exam with powerful anesthetic Propofol, the report says.
Staffers said Korovin called the shots, announcing, “I’m going first,” before clinic personnel could begin their exam.
The investigation found that Korovan had not been granted privileges by the clinic to be in the procedure room, and that the staff didn’t have any information about her credentials.
Korovin aborted the first attempt because she “could not see very well” and tried again after the scheduled throat exam, the report says.
Federal investigators didn’t interview Korovin because “she has been advised by her legal representative not to discuss the case at this time.”
In another violation of protocol, a staff member used his cellphone to take a photo of Korovin working on the sedated Rivers during one of the procedures.
The unidentified staffer said that maybe Rivers “would like to see this in the recovery area.”
“The facility’s ‘Cell Phone Policy’ last revised January 2014 notes that ‘personal cell phones shall not be used in any patient care areas as this can compromise patient safety,’” the report points out.
A review of records also showed confusion over when Rivers went into cardiac arrest, with some staffers saying it was 9:28 a.m. and others saying it was 9:30.
There were also mistakes admitted by the anesthesiologist, who told investigators she gave Rivers 120 milligrams of Propofol but wrote in records that she administered 300 milligrams.
The anesthesiologist also didn’t get Rivers’ weight before giving her the Propofol, the report says. One staffer told investigators that a “patient’s body weight is very critical for the pre-anesthesia assessment, especially for medication calculations.”
Yorkville Endoscopy officials have until Jan. 7 to fix the flaws in their procedures. Otherwise they risk losing their eligibility to receive federal funds for services provided by Medicare and Medicaid.
While Rivers was resuscitated, she never regained consciousness and died Sept. 4 at Mount Sinai Hospital.
Rivers’ only child, Melissa, has hired high-powered Manhattan law firm Gair Gair Conason Steigman Maloof Bloom and Rubinowitz in anticipation of filing a wrongful death lawsuit against the clinic.