REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
February 24, 2026
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Department of Nursing Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center Department of Nursing Policy and Procedure Manual, included and summarized in Attachments A through C.
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of policies and the report of the review and certification of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manual are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manual are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all manuals are reviewed and revised, as necessary, a minimum of every one, two, or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The manual and policies are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals improve County government operations and provide for the safety, health, and social service needs of county residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration.
The Department of Nursing Policy and Procedures Manual (Nursing Manual) contain policies and procedures regarding department organization, function, and establishes standards of nursing practice. The policies, procedures, standards of patient care, and standards of nursing practice are developed by the Nurse Executives, Nursing Unit Managers, Registered Nurses, and other nursing staff members as appropriate. The Nursing Manual contains 124 policies, of which 93 policies have major revisions (including 37 deletions), 19 policies and the index have minor revisions, and 12 policies were reviewed with no recommended changes.
The Department of Nursing completed the 2025 review of the Nursing Manual and recommends the revisions summarized in Attachment A. The update of this manual is certified in Attachment B.
The 56 policies with major revisions consist of the following:
• Policy No. 101.00 V8 Development and/or Approval of Policy and Procedures - Updated policy review requirements to clarify regulatory requirements. Removed master copy location as all policies are held in the digital platform. Updated committee requirements for policies impacting nursing care.
• Policy No. 103.00 V7 Reference Manuals - Added electronic resources available on the Arrownet.
• Policy No. 202.00 V9 Scope of Service for Nursing - Updated locations of care to add cardiac and stroke, updated hours of operation, and added policy references for topics. Added American Nurses Association Standards of Care for reference. Removed duplicate language.
• Policy No. 204.00 V6 Standards of Care - Changed the term practitioner to nurses. Changed the term accountability to responsibility. Changed the term form to medical record. Updated resources.
• Policy No. 206.00 V6 Responsibility and Accountability of Nursing - Changed the term physician to practitioner. Updated job titles and formatting. Updated resources.
• Policy No. 300.00 V4 Chief Nursing Officer (CNO) - Added Nursing strategic plan and removed standards of nursing care.
• Policy No. 301.00 V11 General Responsibilities - Nursing Personnel - Updated to reflect current practice. Added to Licensed Psychiatric Technician scope. Updated clinical assistant title to medical assistant and added competency requirements. Updated references.
• Policy No. 302.00 V13 Nursing Orientation - Removed specific dates for orientations. Addition of the Nurse Residency Program for new graduate nurses. Clarification on process for Nursing Orientation and unit-based orientations. Removed specifics to classroom training.
• Policy No. 303.00 V8 Staff Education - Removed license training requirements. Removed nurse executive team requirement. Removed annual evaluation and needs assessment, because it is mentioned in another policy. Added annual clinical competency and evaluation.
• Policy No. 306.00 V9 Licenses, Certifications and Courses - Removed duplicate language with Nursing policy No. 313.00 for outside agencies. Updated management of assaultive behavior to reflect new program, updated requirements and clarified language.
• Policy No. 307.00 V8 Patient Classification (Acuity) System - Updated job title to charge nurse. Updated Labor and delivery categories, 1. Postpartum mothers without complications, 2. Antepartum, ongoing triage, non-stress test, and uncomplicated observation, 3. Removed education level, 4. Active labor categories, ruptured ectopic. Updated Mother Baby Categories 1. Second- or third-day cesarean not being discharged, Established breast/bottle feeding, Infants have adequate intake and output, Awaiting lab results, Normal spontaneous vaginal delivery couplet greater than 12 hours post-delivery who is not going to be discharged, Mothers with infants in the NICU, Infant requiring septic work-up who is greater than 12 hours of age, Couplet where the infant requires oral or intramuscular medications, Stable Telemetry-monitored patient, 2. Cesarean section, gynecology patients, feral demise, patient-controlled analgesia, direct care from critical care 3. Couplet with chorioamnionitis, readmission, measure every 2 hours, 4. Transitional baby for 60 minutes.
• Policy No. 312.00 V7 Floating and Cross Training - Removed specific law names title, 22, and title 16. Added Memorandum of Understanding (MOU) language for float requirements. Removed specific unit names and added categories of care. Updated references.
• Policy No. 313.00 V9 Contract / Registry Agency Personnel - Updated required certifications and qualifications. Updated policy requirements, adding language for Administrative and Nursing policies. Clarified license verification with the Board of Registered Nurses. Updated legal name requirements on identification and licenses/certifications. Updated orientation form requirement and evaluation with charge nurse. Updated sign-in process and overtime process. Removed Meditech language. Updated resources.
• Policy No. 316.00 V6 Staffing System - Removed automated staffing system. Changed prepared and posted to “published”. Added “or designee” to schedule creation responsibilities. Removed in writing for schedule changes. Removed hours of shifts, definitions of full-time and part-time, language of permission for sleeping, language on punctuality and workers compensation, as this is all contained in Human Resource (HR) Policies. Updated who staff are required to call when calling off and removed making the call “personally”. Removed time and attendance and leave forms, as they are an HR process. Removed all staffing guidelines for the units, as this is contained in Nursing policy No. 307.00. Updated references.
• Policy No. 317.00 V5 Staffing - Removed specific titles and added “unlicensed nursing staff”. Updated the procedure to remove specifics of nurse numbers and added reference to the staffing matrix and patient acuity. Added responsibility for qualified staff being available to the department of nursing. Updated responsibility for the assignment to charge nurse/Assistant Unit Manager. Removed specific language on adjustments as this is located in other policies and the Memorandum of Understanding and is duplicate language. Added language about ratios.
• Policy No. 318.00 V4 Code Team Registered Nurse - Added code team responsibilities for documenting and collecting and maintaining quality and process improvement data. Removed central line dressing change requirements as, this is located in the central line policy.
• Policy No. 401.00 V6 Nursing Management Responsibilities - Updated to add Nurse Executive Team. Added Regulatory Readiness activities, performance improvement activities, and adherence to job description.
• Policy No. 402.00 V6 Meetings, Department of Nursing - Removal of Interdisciplinary committee, added Nursing Standards Committee
• Policy No. 405.00 V8 Integrating and Coordinating Services with Other Departments - Clarified Pressure Injury Nurse. Updated nursing scope and use of collaboration. Removed “care conferences”. Removed patient education for other departments. Changed the term Physician to Practitioner.
• Policy No. 408.00 V7 Chain of Command / Conflict Resolution - Removed specific job titles and referred to the organizational and departmental organizational charts. Removed notification specifics for call or page. Updated emergency only for telephone orders. Updated reference for chain of command policy in Administrative policies. Updated chain of command flow chart. Removed attachment.
• Policy No. 409.00 V7 Decision Making - Added shared governance. Updated clinical decisions to collaborate with key stakeholders. Added Chief Nursing Officer as final decision maker.
• Policy No. 410.00 V5 Communication - Added computer communication. Updated memoranda for internal and external memos. Updated mailbox areas. Removed Meditech and replaced with electronic health record.
• Policy No. 411.00 V8 Critical Patients: Supervisory Notification of - Added Charge Nurse
• Policy No. 412.00 V5 Standardized Procedures - Added Patient Safety Quality Committee approval. Added updated review requirements. Attachment updated. Committees updated.
• Policy No. 413.00 V6 Patient Care References - Updated Library responsibilities, removed procurement, updated references.
• Policy No. 414.00 V3 Research - Updated references, removed process for non-nursing research.
• Policy No. 416.00 V8 The Medical Record - Removed all language that was not nursing specific. Updated process to reflect electronic health record and remove paper references. Removed the purpose statement. Added the Chief Nursing Officer to Form approval. Removed requirements for other departments.
• Policy No. 418.00 V6 Medical Direction - Removed physician requirements, refer to Medical Staff Bylaws. Removed paper copies and added references to digital references. Removed all language of medical staff requirements. Updated References.
• Policy No. 506.00 V4 Tubing Misconnections - Removed reasons for misconnections including, luer connections, unintended use, movement and inattention. Added label verification. Removed specific times for verification. Removed reference to Nursing policy no. 580.10. Updated resources.
• Policy No. 508.00 V5 Patient Care Bundle to Enhance the Patient Experience - Updated language for Hourly Rounding to Pain, Position, Potty, and Proactive Measures. Responsibility updated to unit leadership. Added clarification for inpatient units. Added electronic documentation. Removed specific scripts. Bedside report exemptions removed for confidentiality and added “applicable situations”. Updated references.
• Policy No. 516.00 V4 Postmortem Care - Changed the term physician to practitioner. Added census language related to the deceased. Removed preparation of the deceased for viewing. Added electronic health record. Updated grammar and references.
• Policy No. 520.00 V4 Documentation, Nursing - Removed Meditech added electronic health record language. Updated job title of attendant to patient care assistant, certified nursing assistant, and student nurse. Changed plan of care from daily to every shift. Added reference to department specific policies for assessment time frames. Removed specifics for “real time” documentation. Removed handwritten documentation. Removed chart checks. Added Intake and Output requirements. Updated references.
• Policy No. 528.05 V2 Electronic Healthcare Record (EHR) Downtime Documentation Procedure - Removed Meditech language and updated title.
• Policy No. 543.00 V5 Warming Cabinets: Use and Monitoring of - Removed specific locations and changed specific temperatures to state manufacturers guidelines.
• Policy No. 544.00 V3 MRI Screening - Grammar and formatting updated. Removed the term physician and replaced with practitioner. Removed sticker that is no longer in use. Title changed.
• Policy No. 552.05 V2 Blood Culture Specimen Collection - Removed time separate requirement. Added pediatric and infant draws. Removed specifics for BD Bactec cultures. Removed carry down process and glass bottle language. Changed brand names to generic terms, updated references, and removed detailed process.
• Policy No. 554.00 V4 Flexi-Seal Signal Fecal Management System (FMS) - Updated to add updated manufacturers guidelines and processes. Removed brand names and replaced with generic terms. Removed intervention requirements. Removed step-by-step process in policy and added reference link. Clarified documentation process.
• Policy No. 555.00 V4 Plasmapheresis Services - Updated contact numbers, changed the term physician to practitioner, and updated language for medical record. Removed specific line names.
• Policy No. 555.01 V7 Enteral Tube Feeding Procedures - Removed language regarding enteric coated tablet, removed administration flow, and removed nutrition formulas. Removed specific pill examples. Removed paper documentation process. Updated references, removed specific process and added link to Nursing reference.
• Policy No. 555.02 V3 Chest Tube Management - Removed specific equipment from cart. Removed air leak for chamber. Removed physician process for insertion.
• Policy No. 557.01 V4 Patient Handoff and Communication - Updated to add introduction and questions, removed ticket to ride that is no longer used. Added avoidance of verbal report. Added digital option. Removed manager responsibility. Updated references.
• Policy No. 561.00 V12 Patient Assessment - Updated language to licensed nurse. Removed specific assessment descriptions when the assessment is located in a different policy. Removed outpatient, condensed locations into categories. Removed specifics for documentation and added reference to documentation policy. Updated references.
• Policy No. 561.01 V4 Patient Weight Frequencies - Added end stage renal disease to daily weights and end stage renal disease on dialysis to before and after dialysis. Grammar and references updated.
• Policy No. 564.00 V8 Patient Transfers In-House and Interagency - Removed Bed Management, removed collaboration language. Removed skin assessment. Removed specific job titles and added nurse leadership.
• Policy No. 567.00 V6 24-Hour Nursing Supervisor Report (Communication) - Title change to House Supervisor Shift Report. Updated job title from Nursing Supervisor to House Supervisor. Removed specific time frame of 7 years and referred to the administrative policy. Updated references.
• Policy No. 571.00 V15 Medication Administration: General Guidelines and Safe Practices - Removed television volume. Updated hand hygiene to before and after medication administration, removed weekly medication room inspections.
• Policy No. 571.01 V7 Bedside Medication Verification and Medication Administration - Removed Meditech language and replaced with electronic health record, changed physician to practitioner and updated downtime procedures and updated references.
• Policy No. 572.00 V7 Medication Administration Record (MAR) Documentation Process - Removed paper documentation process and Meditech language changed to electronic health record. Removed staff education requirement. Updated references.
• Policy No. 580.00 V11 Intravenous (IV) Therapy: General Policies - Removed specifics for central line for duplication in the central line policy. Updated references and updated verbiage to practitioner.
• Policy No. 585.00 V8 Pain Management Utilization Patient Controlled Analgesia - Removed patient mental status. Added patient handoff to verification process. Removed Attachment A. Removed pain assessment. Removed specific language to Pasero scale. Added at a minimum, removed at least language. Removed waste language. Removed reportable conditions and practitioner notification. Removed to keep open intravenous fluids, bedside supplies, and emergency measures. Updated resources, removed by proxy definition. Removed attachment A.
• Policy No. 585.01 V4 Pain Management Utilizing Continuous Epidural Infusion or Patient Controlled Epidural analgesia Infusion of Local Anesthetics and Opioid Agents - Removed Labor Pain, changed the term provider to practitioner, removed bedside supplies. Removed additional duties for Labor and Delivery nurses. Updated rapid response team.
• Policy No. 800.00 V6 Wound Care Nurse Consultant, Inpatient - Changed all documentation language to electronic health record, changed the term physician to practitioner. Updated resources.
• Policy No. 802.00 V1 Wound Therapy, Negative Pressure - Added language for hyperbaric oxygen therapy. Remove enzymatic therapy. Added days for Wound Vac Nurse. Removed specific reasons for consultation. Added wound dressing orders per practitioner.
• Policy No. 820.00 V7 Chemotherapy Administration, Patient Management, Preparation and Safe Handling - Changed the term physician to practitioner. Fixed grammar. Updated resources.
• Policy No. 830.00 V3 Chemotherapy Extravasation - Changed the term physician to practitioner, updated follow-up time frames.
• Policy No. 840.00 V5 Chemotherapy Safe Handling, Accidental Spill Procedure, Disposal, Safety Issues and Post Exposure Management - Changed the term physician to practitioner.
There are 37 policies that were deleted. These policies contained outdated processes, equipment that is no longer in use, duplicate language in other policies, or were moved to the appropriate policy manual.
• Policy No. 102.00 V5 Policy and Procedure Manuals - Policy deleted. Administrative Policy 100.03, Policy and Procedure Manuals, cover the content required.
• Policy No. 203.00 V4 Recruitment and Retention - Policy deleted. ARMC does not currently have a Nurse Recruiter.
• Policy No. 304.00 V9 Annual Clinical Competency/Evaluation - Policy deleted and contents added to Nursing Manual Policy No. 303.00 v8.
• Policy No. 309.00 V5 Bed Assignments - Policy deleted. Nursing Manual Policy No. 202.02 covers the content required.
• Policy No. 315.00 V4 Care Assignments - Policy deleted. Care assignments are part of staffing in Nursing Manual Policy Nos. 316.00 and 307.00
• Policy No. 406.00 V4 Maintenance of Required Records and Statistical Information - Policy deleted. Content is covered in Administrative policies.
• Policy No. 415.00 V4 Length of Stay - Policy deleted, not appropriate as a nursing policy. Policy already exists in Utilization Management.
• Policy No. 417.00 V4 Access to the Medical Record - Policy deleted. This is a duplicate of Administrative and Medical Record policies.
• Policy No. 503.00 V4 Seizure: Precautions and Management - Policy deleted. Precautions are located in nursing references.
• Policy No. 505.00 V3 Patient Referral-Substance Abuse, Mental Illness - Policy deleted. This is not a nursing process.
• Policy No. 509.00 V4 External Fixator - Assessment and Management of - Policy deleted. Care for the external fixator is located in nursing resources.
• Policy No. 510.00 V1 Active Surveillance Cultures for MRSA - Policy deleted. This is a duplicate of an Infection Control Policy.
• Policy No. 523.00 V6 Multidisciplinary Rounds - Policy deleted. The policy content is covered in policies in the Administrative Manual. Language moved to Administrative Policy No. 600.05.
• Policy No. 526.00 V5 Vital Signs Routine - Policy deleted. Vital signs are ordered by the practitioner in the electronic health record.
• Policy No. 527.00 V4 Charting: 24 Hour Intake and Output Record - Policy deleted. Requirements combined with documentation policy.
• Policy No. 527.01 V4 Fluid Restriction - Policy deleted. This is not a nursing process; fluid restriction requirements are ordered by the practitioner.
• Policy No. 528.00 V6 Guidelines for Charting in the Meditech Patient Care System (PCS) - Policy deleted. Meditech is no longer in use.
• Policy No. 530.00 V10 Practitioner Orders - Policy deleted; duplication language to Administrative Policy No. 610.39.
• Policy No. 531.00 V3 Practitioner Orders: Transcription - Policy deleted. This is no longer a process used.
• Policy No. 532.00 V3 Consultants, Notification of - Policy deleted. This is not a required nursing policy.
• Policy No. 533.00 V6 Diet Orders - Policy deleted, duplication to dietary policy.
• Policy No. 540.00 V4 Safety Policy Statement: General Overview - Policy deleted due to duplicate language with other policies, including customer service, safe patient handling, and visitor safety.
• Policy No. 541.00 V5 Bed Side Rails, Use Of - Policy deleted, side rails are discussed in restraint policy.
• Policy No. 541.10 V3 Patient Safety - Policy deleted, duplicate with Administrative and other policies.
• Policy No. 548.00 V2 Deep Vein Thrombosis / Venous Thromboembolism Risk Assessment - Policy deleted, this is a physician process and has changed in Epic.
• Policy No. 556.00 V4 Admission Standards - Policy deleted, duplicate of an administrative policy.
• Policy No. 557.00 V8 Admission of a Patient - Policy deleted, duplicate of an administrative policy.
• Policy No. 562.00 V2 Care of the Dying Patient or Patient Near the End of Life - Policy deleted. Nursing items integrated into Administrative Policy No. 910.03.
• Policy No. 573.00 V5 Automated Drug Distribution System (Pyxis) - Policy deleted. Pharmacy policy covers this content.
• Policy No. 576.00 V2 Suspected Adverse Drug Reaction Report Form Procedure - Policy deleted. Pharmacy policy covers this content.
• Policy No. 577.00 V3 Storage of Drugs and Biologicals - Policy deleted. Pharmacy policy covers this content.
• Policy No. 578.00 V2 Statement of Principles Involved in Use of Investigational Drugs at ARMC - Policy deleted. Pharmacy policy covers this content.
• Policy No. 579.00 V5 Food Storage and Refrigeration - Policy deleted. Duplicate language with Nutrition Policy No. 208.00.
• Policy No. 580.10 V5 Intravenous (IV) Infusions Via Infusion Pump - Policy deleted. New infusion pumps obtained which are not covered in this policy and manufacturers’ guidelines are readily available.
• Policy No. 584.01 V5 Propofol Sedation Guidelines for Mechanically Ventilated Patients - Policy deleted. Not a required policy.
• Policy No. 601.00 V3 Communication of Patient Information - Policy deleted, confidentiality policies are in the administrative policy manual.
• Policy No. 603.00 V4 Leave Against Medical Advice (AMA) and Elopement - Policy deleted, this is not a nursing function.
There are 19 policies and the index have minor revisions. These policies contain minor grammatical revisions.
On January 27, 2026 (Item No. 9), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on January 21, 2026; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on January 30, 2026; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on February 2, 2026.