ANM Regulatory Compliance and Accreditation Flashcards
6 cards from real ANM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 ANM Regulatory Compliance and Accreditation flashcards as text
Which Joint Commission National Patient Safety Goal (NPSG) specifically addresses improving the accuracy of patient identification?
Answer: NPSG.01.01.01 — Use at least two patient identifiers when providing care, treatment, or services
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.
Under the CMS Hospital Conditions of Participation, what is the required minimum for registered nurse coverage on a patient care unit?
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
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.
What is the purpose of a Root Cause Analysis (RCA) in the context of regulatory compliance and accreditation?
Answer: To systematically identify the underlying system or process failures that contributed to a sentinel event or near-miss
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.
Which document serves as the primary compliance framework that an ANM references to understand the standards their unit must meet for Joint Commission accreditation?
Answer: The Joint Commission Comprehensive Accreditation Manual for Hospitals (CAMH)
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.
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:
Answer: A variance or incident report, reviewed for trends to prevent future patient falls
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.
When a new federal or state regulation affecting nursing practice is enacted, what is the ANM's primary responsibility?
Answer: Ensure all unit policies and staff practices are updated to align with the new regulation before its effective date
The ANM is responsible for proactively updating unit-level policies and educating staff to achieve compliance with new regulations before the effective date.