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Based on observation and staff interviews the facility failed to provide accurate evacuation diagrams per NFPA 101-2012 Edition, Section 19.2.10.1, NFPA 101-2012 Edition, Section 7.10.8.5*, NFPA 101-2012 Edition, Section 7.10.3.2*, and NFPA 170-09 Edition, Section 9.4*. This had the potential to affect all the patients, staff, and visitors at the time of the survey.

Findings include:

An observation during a tour of the facility with Plant Operations on 02/28/24 at approximately 1:28 P.M. revealed there was no evacuation map displayed on the 3rd floor B-side. Also, the evacuation maps displayed on the C-side, B-side, and Oncology of the building did not display floor arrangement that included primary and secondary exits, YOU ARE HERE symbols, the location of pull stations, and fire extinguishers like the arrangement in the Emergency Departments (ED).

An interview with Plant Operations on 02/28/24 at approximately 1:28 P.M. verified the finding by stating that the building was built at different times, and at one point the 3rd floor was closed off. The Plan Operation Personnel stated, "it appears not to be in public site".

NFPA 101-2012 Edition, Section 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10 unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
NFPA 101-2012 Edition, Section 7.10.8.5* states, that where a posted floor evacuation diagram is required in Chapters 11 through 43, floor evacuation diagrams reflecting the actual floor arrangement and exit locations shall be posted and oriented in a location and manner acceptable to the authority having jurisdiction.
A.7.10.8.5 Egress paths with multiple turns can often be confusing with respect to which exit route will lead to the closest exit door. Floor evacuation diagrams can eliminate the guesswork by giving the occupant a point of reference with the YOU ARE HERE symbol. The entire floor plan should be shown with the primary and secondary exit routes, exit stairs, and elevators identified. For further information see ASTM E 2238, Standard Guide for Evacuation Route Diagrams.
NFPA 101-2012 Edition, Section 7.10.3.2* Where approved by the authority having jurisdiction, pictograms in compliance with NFPA 170, Standard for Fire Safety and Emergency Symbols, shall be permitted.
NFPA 170-09 Edition, Section 9.4 Information Shown.
NFPA 170-09 Edition, Section 9.4.1 The information in 9.4.1.1 and 9.4.1.2 shall be shown on the plan area of the diagram or plan. Additional information shall be permitted to be added if it does not confuse the viewer during an emergency.
NFPA 170-09 Edition, Section 9.4.1.1 The means of egress from the viewers' location shall be shown. This shall include all exit locations, exit access paths, stairways, elevators, elevator lobbies, areas of refuge, areas of rescue assistance, shelter areas, and exterior outside assembly areas.
NFPA 170-09 Edition, Section 9.4.1.2 The equipment used during an emergency shall be shown in a key or legend. This key or legend shall include fire alarm pull stations, emergency phones, defibrillators (AED), fire extinguishers (if trained to use properly), or any other building-specific emergency equipment.
NFPA 170-09 Edition, Section 9.4.2 The diagram or plan shall provide emergency phone numbers.
NFPA 170-09 Edition, Section 9.4.3 The diagram or plan shall provide emergency evacuation guidelines describing the emergency alert signals and when and what to do when the signals are sounded. If there are not any signals, the guidelines shall describe how the occupants will be instructed what to do in case of an emergency.
NFPA 170-09 Edition, Section 9.5 Construction. The diagram shall be constructed with materials that protect it from fading and wear.

Based on record review, observation, and interview the facility failed to provide an accurate location of a code red announcement per NFPA 101-2012 Edition, Section 19.7.2.1*. This had the potential to affect all patients, employees, and visitors.

Findings include:

Record review of the Mercy Health - Toledo Metro / CODE RED - Fire Plan effective date 01/1968 under the announcement section it stated, "When a pull station or a smoke detector has gone into alarm, the Campus Police Dispatch Center will initiate the Public Address System to state, "Attention all personnel, Code Red Fire, and fire location". This announcement will be repeated three times.

A record review of the licensed contractor pulls station report dated 01/20/24 on 02/28/24 at approximately 1:00 P.M. revealed the location of the pull stations N2-L2-M008 in the café building C, and L1-M015 was located by 3rd floor elevator.

An observation during a test of the fire alarm, using the pull station labeled N2-L2-M008 on 02/28/24 at approximately 1:38 P.M. by the Outpatient Pharmacy revealed an announcement was made over the intercom that there was a Code Red located in the Oncology Lobby. Also, during a second test of the fire alarm using the pull station L1-M015 located on the 1st-floor lobby, near the chapel on the C-side of the building, a Code Red announcement stated the emergency was in oncology. Resulting in an inaccurate description of where the Code Red was located.

An interview with Plant Operations on 02/28/24 at approximately 1:38 P.M. after a test of the fire alarm verified the finding by stating, "Good question" and again after a second test of the fire alarm in a different location at approximately 1:28 P.M. by stating, "Because it is in building B".

NFPA 101-2012 Edition, Section 19.7.2.1* Protection of Patients.
NFPA 101-2012 Edition, Section 19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.
NFPA 101-2012 Edition, Section 19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan
NFPA 101-2012 Edition, Section 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to the fire department
(3) Emergency phone call to the fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire