The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST. MARY'S HEALTH, INC. 3700 WASHINGTON AVE EVANSVILLE, IN 47750 Dec. 6, 2013
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on documentation review, observation, and staff interview, the Governing Board failed to ensure the contracted foodservice properly cooked raw hamburger and raw chicken to the required cooking temperatures; failed to ensure proper holding temperatures of cooked food; and failed to ensure dietary staff wash their hands as required by state law, 410 IAC 7-24.

Findings included:

1. The foodservice contract provider with St. Mary ' s Medical Center Evansville was approved January 13, 2013. The contract between the foodservice contract providers with St. Mary Medical Center Evansville Inc. shall adhere to all local, state, and Federal rules and regulations.

2. Retail Food Establishment Sanitation Requirements 410 IAC 7-24-129 indicates; When to Wash Hands: Food employees shall clean their hands and exposed portions of their arms as specified under section 106 immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and the following: After touching bare human body parts other than clean hands and clean, exposed portions of arm; After coughing, sneezing, or using a handkerchief or disposable tissue; After handling soiled surfaces, equipment, or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; When switching between working with raw food and working with ready-to-eat food; Before touching food or food-contact surfaces; Before placing gloves on hands; After engaging in other activities that contaminate the hands.

3. Retail Food Establishment Sanitation Requirements 410 IAC 7-24-182 indicates; Cooking of Raw Animal Foods: Raw animal foods, such as eggs, fish, meat, poultry, and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one (1) of the following methods based on the food that is being cooked: One hundred fifty-five (155) degrees Fahrenheit for Comminuted meat or fish; One hundred sixty-five (165) degrees Fahrenheit or above for poultry, game animals, stuffed fish, stuffed meat, stuffed pasta, stuffed poultry, or stuffing containing fish, meat, or poultry.

4. Indiana Retail Food Establishment Sanitation Requirements 410 IAC 7-24-187 indicates; Except during preparation, cooking, or cooling; potentially hazardous food shall be maintained as follows: At one hundred thirty-five (135) degrees Fahrenheit or at forty-one (41) degrees Fahrenheit or less.

5. At 10:15 AM on 12/3/2013, three staff that was working on the Patient Service Line was observed multiple times changing their gloves without washing their hands in between the changing of the gloves. One staff member, who was working at the fry station of the Patient Service Line, was observed placing raw pork cutlets on the grill with his/her bare hands then followed-up putting on single-use gloves without washing his/her hands first.

6. At 10:30 AM on 12/3/2013, the Patient Serving Line station was observed in the kitchen. The grill station changed from breakfast items to lunch items. The grill station staff member was observed grilling raw hamburgers and raw chicken breast. The grill station was observed with two 4-inch deep pans of water on the grill surface top. The grill station staff member was observed placing 18 grilled chicken breasts in one container and 20 grilled hamburger patties in the other container that were just grilled. Four randomly selected chicken breasts tempted between 118 to 127 degrees Fahrenheit. Three randomly selected hamburgers tempted between 112 to 119 degrees Fahrenheit. The grill station staff member sliced one chicken breast in half and the chicken breast was pink in the middle. Both items were cooked from raw on the grill and were not cooked to the required cooking temperatures of 165 and 155 degrees Fahrenheit respectively. Several hamburgers were observed already placed on a patient's transport cart.

7. At 10:45 AM on 12/3/2013, the fryers located adjacent to the Patient Service Line's grill were observed with French fries in one basket and breaded fish squares in the other basket. Both items had been deep fried and were draining above the hot grease for at least 15 minutes. There were at least 25 deep fried fish squares in one of the fryer's baskets. One fish square tempted at 119 degrees Fahrenheit. The fish squares were not held at the required temperature of 135 degrees Fahrenheit.

8. At 11:00 AM on 12/3/2013, staff member #6 confirmed the staff did not cook the raw chicken and the raw hamburger on the patient service line grill to the required temperatures of 165 and 155 degrees Fahrenheit respectively. The staff member indicated the procedure of the patient tray line was to grill the food as it was ordered by a patient. The staff member indicated the dietary staff members are not to grill the food and place it in a container of water on the grill and hold it waiting for a patient to order it. The staff on the patient tray line was not following proper procedures to grill patient food as ordered. The staff member indicates the same thing goes for the fish squares. The patient serving line staff members are not to deep fry a lot of fish when they are not ordered by the patient.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and staff interview, the facility failed to ensure the foodservice contractor was part of it's comprehensive quality assessment and improvement (QA&I) program.

Findings included:

1. The foodservice contractor with St. Mary's Medical Center Evansville was approved January 13, 2013. The contract specifies that both parties have agreed to measure Supplier's performance with respect to the following performance areas: Patient Satisfaction, retail foodservice customer satisfaction, and employee satisfaction. The foodservice contract with St. Mary Medical Center Evansville Inc. shall adhere to all local, state, and Federal rules and regulations.

2. The Quality Performance Improvement reports were reviewed. The contracted foodservice provider has not been monitored and evaluated by the hospital.

3. At 1:30 PM on 12/5/13, staff member #2 confirmed that the contracted service has not been monitored or evaluated for its performance standards since they became the contracted foodservice provider for the hospital.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, documentation review, and staff interview, the facility failed to maintain the Production Kitchen in a sanitary manner.

Findings included:

1. At 9:40 AM on 12/3/2013, the Patient Serving Line in the Production Kitchen was inspected. The floor surfaces under the kitchen equipment and the serving line were observed with heavy accumulation of food debris and other soil residue. The floor was greasy to touch. Three of three sanitizing wiping cloth containers that are used to wipe food-contact surfaces registered less than 100 parts per million quaternary ammonia. The manufacturer requires the concentration to be between 150 and 400 parts per million quaternary concentration for it to be effective against bacteria that can contribute to a food borne infection.

2. At 10:00 AM on 12/4/2013, the sanitation of the Production Kitchen was inspected. The Patient Service Line was observed with soiled rags stored on prep tables and on shelves under the prep tables. The rags were not stored in the food-contact sanitizing container as required by 410 IAC 7-24. The floor surface was also observed heavily soiled with loose food debris on it and greasy to the touch.

3. At 10:30 AM on 12/4/2013, the food production area was observed with the floor heavily soiled with loose food deposits. One lower shelf of one of the prep tables was observed rusty with loose food on the shelf. The exterior surfaces of the cooking equipment were observed greasy with accumulation of soil residue on them. Under the steam jacket kettles, there was a pan under a drain pipe collecting drips from the pipe. The pan was filled with black water. The floor behind the cooking equipment was observed heavily soiled with dirt and food.

4. At 12:05 PM on 12/4/2013, staff member #5 confirmed the sanitation of the kitchen was dirty and assorted food debris was accumulated throughout the kitchen floor surfaces. The kitchen equipment was soiled and with heavy grease accumulation on them.