REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
January 13, 2026
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
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 Operations, Policy and Procedure Manuals, included and summarized in Attachments A through O:
1. Labor and Delivery Policy and Procedure Manual
2. Maternal Child Health Policy and Procedure Manual
(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 Labor and Delivery Policy and Procedure Manual (LND Manual) contains policies and procedures required by regulation or determined by ARMC Administration that pertain to the specialty. The manual contains 55 policies, of which 14 policies have major revisions (five of these were moved to the Maternal Child Health Policy and Procedure Manual [MCH Manual]), one policy is new, and 40 policies and the table of contents have minor revisions.
The Labor and Delivery Unit completed the 2025 review of the LND Manual and recommends the revisions summarized in Attachment A. The update of this manual is certified in Attachment B.
The 9 policies with major revisions consist of the following:
• Policy No. 120.04 v11. Scope of Service - Labor and Delivery - Removed specific patient ratios and referred to the Department of Nursing Policy 307.00. Removed Licensed Vocational Nurse (LVN) from the core staffing because the unit does not staff LVNs. References updated.
• Policy No. 203.00 v10. Placentas, Handling and Disposal of - Updated the policy to reflect the current workflow in the electronic health record. References updated.
• Policy No. 206.00 v2. Observation Status in Labor and Delivery - Updated the title from “Observation in Labor and Delivery, Limited” to “Observation Status in Labor and Delivery” to reflect the wording used in the order in the electronic health record. Updated the observation time to reflect Administrative Policy 610.40. References updated.
• Policy No. 214.00 v13. Triage of the Obstetrical Patient in Labor and Delivery - Updated the wording to reflect the Maternal Fetal Triage Index, which is the triage algorithm currently in use. The references were updated to reflect this change. Removed the contents of the admission packet provided by the registration clerk. Added Care Assistant to staffing as they are currently used in Labor and Delivery triage.
• Policy No. 220.00 v10. Documentation Guidelines - Updated the policy to reflect the current workflow documentation in the electronic health record. References updated.
• Policy No. 240.00 v13. Post Delivery Management of the Mother - Updated the wording to practitioner and electronic health record. Included all vital signs to be recorded and added skin-to-skin patient education. Updated the epidural removal workflow. References updated.
• Policy No. 247.00 v11. Fetal Heart Rate and Uterine Monitoring - The policy was updated to include the nursing response to signal ambiguity to reflect Beta Healthcare Group, Quest for Zero: Obstetrics requirements. References updated.
• Policy No. 256.00 v7. Sponge Lap, Needle, and Instrument Count, Vaginal Delivery - Updated the wording to describe counting and documenting the items used in a vaginal delivery. Removed the sections describing documenting the date and time of delivery table set up on a sticker and placing it on the table. This is no longer the current practice since table set up is documented in the electronic health record and time stamped. Removed section stating “Encourage persons in the delivery room to wear clean gowns, caps, and masks during a delivery” as this is no longer current practice. References updated.
• Policy No. 259.00 v4. Urine Pregnancy Testing - Removed brand names from the Procedure section. References updated.
There is one new policy. The new policy added to the manual is included in Attachment C and consists of the following:
• Policy No. 303.00 v1. Standardized Procedure: For Registered Nurses within the Labor and Delivery Department Triage - This is a new policy describing the standardized procedure that registered nurses are to follow when assessing patients presenting to Labor and Delivery triage.
The 5 policies that were moved to the MCH Manual consist of the following:
• Policy No. 211.00 v2. Blood Loss, Cumulative Quantitative Assessment - This policy was moved to the MCH Manual, Policy 5302.00 Issue 1 because it applies to both the Labor and Delivery and Mother-Baby units.
• Policy No. 217.00 v1. Bakri Postpartum Balloon, Insertion and Management of - This policy was moved to the MCH Manual, Policy 5273.00 Issue 1, because it applies to both the Labor and Delivery and Mother-Baby units.
• Policy No. 242.00 v1. Sepsis and Septic Shock, Care of the Patient - This policy was moved to the MCH Manual, Policy 5301.00 Issue 1 because it applies to both the Labor and Delivery and Mother-Baby units.
• Policy No. 245.00 v5. Obstetrical Emergencies - This policy was moved to the MCH Manual, Policy 5261.00 Issue 1 because it applies to both the Labor and Delivery and Mother-Baby units.
• Policy No. 246.00 v6. Incarcerated Patients, Care of - This policy was moved to the MCH Manual, Policy 5302.00 Issue 1 because it applies to both the Labor and Delivery and Mother-Baby units.
There are 40 policies that contain minor revisions. These revisions consist of minor grammatical revisions and specifications of acronyms.
The MCH Manual contains policies and procedures required by regulation or determined by ARMC Administration that pertain to the specialty. The manual contains 63 policies, of which 27 policies have major revisions (including three policies that were deleted), nine policies are new, 24 policies and the table of contents have minor revisions, and three policies were reviewed with no recommended changes.
The Maternal Child Health Unit completed the 2025 review of the MCH Manual and recommends the revisions summarized in Attachment D. Update of this manual is certified in Attachment E.
The 24 policies with major revisions consist of the following:
• Policy No. 5150 v2 Admission and Transfer Criteria: Newborn Nursery and Neonatal Intensive Care Unit (NICU) - The neonatal intensive care unit (NICU) and Newborn Nursery admission criteria were updated. The NICU and Couplet Care transfer criteria were updated.
• Policy No. 5205 v3 Safe Sleep - The title of the policy was changed from “Back to Sleep, Positioning for Safe Sleep” to “Safe Sleep”. Per current recommendations, updated educating parents regarding Sudden Unexpected Infant Death (SUID), which includes Sudden Infant Death Syndrome (SIDS), and removed the term SIDS. Removed text describing American Academy of Pediatrics (AAP) guidelines for safe sleep and added the AAP Guidelines Summary of Recommendations with Strength of Recommendations as Attachment A.
• Policy No. 5205.1 v3 Bassinet and Crib Use, Standards - Changed the title from “Bassinette Technique, Individual” to “Bassinet and Crib Use, Standards.” Simplified & shortened the policy.
• Policy No. 5206 v4 Bladder Catheterization for Neonates and Pediatrics - Removed Purpose section. Revised Procedures section. Deleted the rest of the policy.
• Policy No. 5208 v2 Breastfeeding: Encouraging, Supporting, and Assisting - Added the assessment process for Antepartum patients. Restructured bonding and attachment section.
• Policy No. 5209.1 v5 Breastmilk Collection, Storage, and Usage - Updated Attachment A Contraindications for Breastfeeding.
• Policy No. 5209.2 v4 Breastmilk: Pasteurized Donor Human Milk Administration - Removed attachments and added a section to outline the procedure for Mother Baby/Pediatric nurses.
• Policy No. 5214 v4 Congenital Heart Disease Screening - Edited how to obtain oxygen saturation values. Corrected oxygen saturation value from 95% to 94%. Edited when to call provider, after second failed test vs third failed test. Removed Title 22 reference.
• Policy No. 5216 v8 Drug Withdrawal: Neonatal Opiate Exposure - Removed the pharmacological table. Updated Attachment A, which is practitioner’s Epic order set and serves as a guide.
• Policy No. 5218 v3 Erythromycin Administration - Updated language regarding that both eyes are treated within two (2) hours, and added “not to exceed six (6) hours.”
• Policy No. 5228 v5 Hepatitis B: Screening, Preventing, and Reporting - Updated reporting information, removed reporting form as attachment, and updated references.
• Policy No. 5230 v6 Hypertensive Crisis; Care of the Patient - Removed specific resident and phone number to notify. Removed medication names, referring to “first-line antihypertensive medication.” Added treatment algorithm as Attachment A. Updated language and references.
• Policy No. 5232 v5 Hypoglycemia, Management of the Neonate with - Completely restructured policy, updated standards of care and glucose levels per American Academy of Pediatrics & Academy of Breastfeeding Medicine.
• Policy No. 5233 v7 Identification of the Newborn - Updated to reflect new serialized infant bands. Removed Attachment A. Updated verbiage (electronic health record) and signature table.
• Policy No. 5245 v9 Miscarriage, Stillbirth, or Live-born Periviable Neonate, Care of - Removed Attachment D, Request for Tissue Examination. Updated Labor and Delivery (L&D) cart to L&D pack. Updated title of autopsy form and order. Updated electronic health record (EGR) language. Referenced Labor and Delivery policy 203.00 regarding placentas. Updated process for ordering laboratory testing per Epic. Updated ordering Social Work consultation per Epic. Added language regarding documentation and workflow in Epic. Updated references. Updated Attachment A, Miscarriage, Stillbirth, and Live-born Periviable Neonates Guidelines to reflect workflow and documentation in Epic.
• Policy No. 5246 v5 Maternal Child Health Census Management Plan - Removed transfer of postpartum patients to Medical-Surgical Unit during census overflow. Replaced with transfer of Gynecologic and stable antepartum patients under 23 weeks with medical admission diagnosis to Medical-Surgical Unit. Removed references to “attending” and replaced with “practitioner.”
• Policy No. 5249 v5 Neonatal Resuscitation Team Plan - Removed role of the Resident/Intern in the delivery/operating room as a member of the resuscitation team. Updated use of respiratory equipment and cardiorespiratory monitoring. Updated documentation.
• Policy No. 5250 v3 Inpatient Newborn Hearing Screening Program - Completely restructured the policy, condensed verbiage and maintained requirements, and added “Important Note” per Department of Health Care Services (DHCS).
• Policy No. 5255 v3 Oxygen Saturation Management and Retinopathy of Prematurity Considerations - Updated oxygen saturation target ranges and alarm limit settings. Specified practitioner notification. Updated monitoring equipment.
• Policy No. 5255.1 v4 Oxygen Therapy Management - Removed section regarding oxyhood, which is no longer being used.
• Policy No. 5257 v4 Phototherapy - Removed obsolete care instructions and edited risk factors for developing hyperbilirubinemia.
• Policy No. 5260 v7 Hemorrhage: Obstetric - Updated title from Hemorrhage: Postpartum. Updated treatment and risk assessment per California Maternal Quality Care Collaborative (CMQCC) guidelines. Updated to Mother-Baby Unit (MBU). Updated workflow for hemorrhages on MBU. Removed written details of hemorrhage stages and added Attachment A with CMQCC guidelines. Removed attachment containing a quantitative blood loss calculator: this is now in the Electronic Health Record. Added communication with and family support per Beta Obstetrics.
• Policy No. 5270 v4 Tdap Vaccine Administration - Added “Do not administer the Tdap vaccine to patients that fall under Centers for Disease Prevention and Control’s (CDC) list of contraindications. (Refer to CDC’s Vaccine Information Statement.” Removed list of vaccine side effects.
• Policy No. 5300 v2 Vitamin K Administration - Edited weight administration, after confirming with pharmacy. Updated the needle gauge size to reflect current practice. Specified administration timeframe.
There are 3 policies that were deleted. The following policies contained outdated descriptions, guidelines and processes that are no longer applicable:
• Policy No. 5201 v3 Baby Friendly Hospital Initiative - This policy was retired because the Maternal Child Health service line is no longer following the Baby Friendly Hospital initiative, but now follows the California Model Hospital Infant Feeding Policy.
• Policy No. 5225 v3 Obstetrical, Pediatric, Pathologic, and Radiologic Conferences - This policy was retired because these conferences are no longer held.
• Policy No. 5227 v3 Hand Hygiene Technique - This policy was retired due to being redundant with Infection Control policy 401.
There are 9 new policies. The new policies added to the MCH Manual are included in Attachments F through N, and consist of the following:
• Policy No. 5261 v1 Obstetric Emergencies - Moved from LND Manual (Policy 245.00 v5). Updated workflow, assessments and response guidelines to address all MCH areas.
• Policy No. 5273 v1 Bakri Postpartum Balloon, Insertion and Management of - Moved from LND Manual (Policy 217.00 v1). Updated references.
• Policy No. 5274 v1 Jada System, Insertion and Management of - New policy to support the use of a vacuum-induced medical device to control hemorrhaging.
• Policy No. 5301 v1 Sepsis and Septic Shock, Care of Patient - Moved from LND Manual (Policy 242.00 v2) Minor changes made to policy text and references updated.
• Policy No. 5302 v1 Blood Loss, Cumulative Quantitative Assessment - Moved from LND Manual (Policy 211.00 v2). Updated workflow to incorporate use of blood loss calculation tools.
• Policy No. 5303 v1 Incarcerated Patients, Care of - Moved from LND Manual (Policy 246.00 v6) Minor changes made to policy text and references updated. Updated workflows and added reference to associated Department of Nursing Policy.
• Policy No. 5304 v1 Model Hospital Infant Feeding Policy - New policy on breastfeeding care and support created to comply with California Hospital Infant Feeding Act.
• Policy No. 5305 v1 Sepsis, Neonatal - Policy moved from Mother-Baby Service Manual (MBS Policy 219.01 v6). Revised policy to address care and management of suspected and actual newborn infections.
• Policy No. 5306 v1 Venous Thromboembolism Monitoring and Prevention - Policy moved from Mother Baby Service Manual (MBS Policy 204.01 v6) Updated risk factors for development and complications of blood clots during and following pregnancy (venous thromboembolism).
There are 24 policies that contain minor revisions. These policies contain minor grammatical revisions and specifications of acronyms.
On December 16, 2025 (Item No. 10), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment O.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on November 26, 2025; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on December 5, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on December 15, 2025.