Max Super

Policy Name – Care of Vulnerable Patients

Specialty Hospital
th JCI – COP 3 & PFR
Reference NABH 4 Ed - COP 10 a, d
1.5

Document Control Page

Document Name: Care of Vulnerable Patients

Version No.: 1.3
Revision No. : 03
Original Date: 01 July 2016
Revision Date: 01 July 2019
Policy Next Review Date (12 months or earlier) & 01 July 2020
Responsible person (Designation): Medical Quality and subject matter experts as applicable

Prepared By : Approved By:

Col. Aarti Dutt Col. Sanjula Verma

(Head Nursing Quality) (GM & Chief Nursing Officer)

Page 1 of 4 version: 1.3

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Max Super
Policy Name – Care of Vulnerable Patients
Specialty Hospital
th JCI – COP 3 & PFR
Reference NABH 4 Ed - COP 10 a, d
1.5

Purpose
 To identify the vulnerable group(s) of patients admitted in the hospital
 To establish and implement guidelines and procedures for the care of vulnerable patients

Scope:
 Inpatients
 Outpatients

Responsibilities:
 The responsibility of identifying and categorizing vulnerable patients lies with the nurses & treating
consultant.

Definitions

‘Vulnerability’ is operationally defined as the potential risk associated with the physical and mental status of an
individual, which might reasonably be anticipated irrespective of the context in which care is provided.

Identification of Vulnerable patient group:

1. Patients in the following groups are considered to be Vulnerable:

 Adolescent patients below the age of 18 years
 Patients above the age of 65 Years
 Patients with impaired mental function (including Frightened and confused patients)
 Patients with limited physical mobility - Any patient who cannot perform their activities of daily living, deaf
& dumb
 Patients having difficulty in communication or has a language problem e.g. a foreigner
 Unconscious patient
 Unescorted female patient
 Terminally ill Patients
 Patients on restraints
 Victims of abuse and neglect
 Drug/alcohol dependent
 Patient with Morse fall score of 45 and above
 All ICU / HDU Patients
2. Every patient coming to hospital shall be screened for their vulnerability. A violet colour ID band as a proper
identification of the vulnerable patient will be applied on the patient by the nursing staff in the ward.
3. A safety violet colored bell (labelled safety first) is placed at the head end of the bed of every vulnerable
patient.
4. A violet sticker is placed on the “door cards” for identification

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Max Super
Policy Name – Care of Vulnerable Patients
Specialty Hospital
th JCI – COP 3 & PFR
Reference NABH 4 Ed - COP 10 a, d
1.5

5. The bed numbers of these patients are labelled with purple colour on the “Care giver/ information board”
6. Patient information material regarding “Fall prevention and safety measures” are distributed to every patient
on admission
7. The hospital does not encourage the admission of patients falling in the above categories, without an
attendant.
8. The hospital establishes and implement guidelines and procedures for the care of vulnerable patients
9. Staff is imparted training on those guidelines, criteria’s and procedures.
10. Identification of vulnerable patients made by:
a) Nursing (Based on Nursing Assessment)
b) Consultant (Based on medical condition)
11. Nursing staff shall institute falls risk strategies as per the risk assessment scale done on the patients and will
record the same in the fall risk assessment form in inpatient care setting and initiate appropriate interventions
and these are documented
12. At the time of initial medical assessment being conducted by doctor, the unique needs of above mentioned
patients shall be considered while documenting the plan of care specific to such patients.
13. At the time of nursing assessment, the special needs of such patients shall be considered and shall be
documented in nursing plan of care.

Safe and Secure environment for Vulnerable patient:

 Training is imparted to all staff on vulnerable patients and patients being provided with high risk
services.
 Providing beds with guard rails are available for use of the patients when the need arises.
 Wheelchairs with proper safety belts and locking facilities are made available.
 Night bulbs are installed in each patient room.
 Lighted pathways are provided for patients to move around at their own pace.
 Safety bars are installed in the washrooms
 Nursing staff will educate the vulnerable patients and their attendants during their stay on patient
safety measures.
 For terminally ill patients the guidelines for the end of life care shall be followed by the staff.
 Care shall be taken to prevent the occurrence of deep vein thrombosis with DVT prophylaxis.
 Frequent postural change shall be done to prevent decubitus ulcers formation in patients who are
immobilised.
 Precautions shall be taken prior to put patients on restraints with appropriate restraint order from the
consultant, consent from the attendant and documentation of the same. Care shall be taken to prevent
ischemic injury to patient’s limbs due to inappropriate method of restraint.
 Standard precautions, adherence to hand hygiene, use of appropriate Personal Protective Equipment,
providing renal diet, routine serological testing, and care of reuse of dialyser shall be taken in
consideration.
 For appropriate management of emergency patients, appropriate clinical practice guidelines will be
followed

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*Uncontrolled, if printed
Max Super
Policy Name – Care of Vulnerable Patients
Specialty Hospital
th JCI – COP 3 & PFR
Reference NABH 4 Ed - COP 10 a, d
1.5

 Care will be taken for appropriate dose and technique to prevent any equipment or technical
failure/over dosage while providing radiotherapy treatment.

Informed Consent
In case of vulnerable patients the consent is taken from the appropriate legal representative (Surrogate Decision
Maker)

Surrogate Decision Maker - The priority order of surrogate decision makers is:
a) Spouse,
b) Adult Children,
c) Parents,
d) Adult Brothers or Sisters,
e) Adult Grandchildren,
f) Significant other (close friend). A close friend may sign the consent form only in an emergency.

Training of Staff
Staff should be trained for care of vulnerable patients with respect to:
 Identifying vulnerable patients
 Providing care to vulnerable patients and patients being provided with high risk services

Evaluation, Monitoring and Compliance:

To ensure compliance to policy, the hospital will conduct regular internal audits (for NABH & JCI). Any variation to
the policy will be captured and documented. Corrective and Preventive actions will be initiated and implemented.
This is a part of quality improvement program.

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