ANM ANM Regulatory Compliance and Accreditation 3

Question 1

Which Joint Commission National Patient Safety Goal (NPSG) specifically addresses improving the accuracy of patient identification?

Accepted Answer

NPSG.01.01.01 — Use at least two patient identifiers when providing care, treatment, or services

Answer

NPSG.01.01.01 requires staff to use at least two patient identifiers (such as name and date of birth) before providing any care, treatment, or service.

Question 2

Under the CMS Hospital Conditions of Participation, what is the required minimum for registered nurse coverage on a patient care unit?

Accepted Answer

An RN must be on duty and responsible for each patient's care on every unit 24 hours a day, 7 days a week

Answer

42 CFR 482.23 requires that a registered nurse must supervise and evaluate nursing care for each patient, with RN presence on every unit 24/7.

Question 3

What is the purpose of a Root Cause Analysis (RCA) in the context of regulatory compliance and accreditation?

Accepted Answer

To systematically identify the underlying system or process failures that contributed to a sentinel event or near-miss

Answer

RCA is a structured process to identify system-level causes of adverse events so corrective actions address root failures rather than surface symptoms, as required by TJC for sentinel events.

Question 4

Which document serves as the primary compliance framework that an ANM references to understand the standards their unit must meet for Joint Commission accreditation?

Accepted Answer

The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH)

Answer

The CAMH is TJC's official manual containing all accreditation standards, elements of performance, and scoring guidelines that ANMs must reference to ensure unit compliance.

Question 5

A staff nurse reports that a patient's side rails were not raised per policy after medication administration. As an ANM, this event should be documented as:

Accepted Answer

A variance or incident report, reviewed for trends to prevent future patient falls

Answer

A policy deviation like raised side rails not being followed is a variance/near-miss that should be incident-reported and trend-analyzed as part of the unit's fall prevention program.

(ANM) Assistant Nurse Manager Certification Practice Test

(ANM) Assistant Nurse Manager Certification Practice Test

ANM ANM Regulatory Compliance and Accreditation 3