File #: 13501   
Type: Consent Status: Agenda Ready
File created: 1/5/2026 Department: Arrowhead Regional Medical Center
On agenda: 1/13/2026 Final action:
Subject: Arrowhead Regional Medical Center Operations, Policy, and Procedure Manuals
Attachments: 1. ATT - ARMC - 1-13-26 - Att D - Maternal Child Health (MCH) Summary of Policy Revisions 2025, 2. ATT - ARMC - 1-13-26 - Att E - Maternal Child Health (MCH) Certification, 3. ATT - ARMC - 1-13-26 - Att F - MCH 5261 v1 Obstetric Emergencies, 4. ATT - ARMC - 1-13-26 - Att G - MCH 5273 v1 Bakri Postpartum Balloon, Insertion and Management of, 5. ATT - ARMC - 1-13-26 - Att H - MCH 5274 v1 Jada System, Insertion and Management of, 6. ATT - ARMC - 1-13-26 - Att I - MCH 5301 v1 Sepsis and Septic Shock, Care of Patient, 7. ATT - ARMC - 1-13-26 - Att J - MCH 5302 v1 Blood Loss, Cumulative Quantitative Assessment, 8. ATT - ARMC - 1-13-26 - Att K - MCH 5303 v1 Incarcerated Patients, Care of, 9. ATT - ARMC - 1-13-26 - Att L - MCH 5304 v1 Model Hospital Infant Feeding Policy, 10. ATT - ARMC - 1-13-26 - Att M - MCH 5305 v1 Sepsis, Neonatal, 11. ATT - ARMC - 1-13-26 - Att N - MCH 5306 v1 Venous Thromboembolism Monitoring and Prevention, 12. ATT - ARMC - 1-13-26 - Att O - ARMC Policy and Procedure Manual Approval List, 13. ATT - ARMC - 1-13-26 - Att A - Labor and Delivery (LND) Summary of Revisions 2025, 14. ATT - ARMC - 1-13-26 - Att B - Labor and Delivery (LND) Certification, 15. ATT - ARMC - 1-13-26 - Att C - LND 303.00 v1 Standardized Procedure for RNs Within the LND Triage
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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 ...

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