Is a Lap Board Considered a Restraint? What Caregivers Must Know

According to the Centers for Medicare & Medicaid Services (CMS), a device is a restraint if it cannot be easily removed by the resident and restricts their freedom of movement. This critical distinction determines if a lap board is considered a restraint, carrying serious implications for patient rights and caregiver responsibilities.

Quick Summary

The classification of a lap board as a restraint is determined by its intended use and whether the individual can remove it easily. If the device restricts a person's freedom of movement and they cannot intentionally remove it, then it is legally considered a restraint, requiring proper medical justification and documentation.

Key Points

• Intent is Key: The primary factor is whether the lap board is used to assist with activities or to restrict a resident's movement.

• Easy Removal Rule: For a lap board to not be a restraint, the resident must be able to remove it easily and intentionally themselves.

• Avoid Fasteners: Boards with buckles, belts, or other mechanisms that hinder removal are almost always considered restraints.

• Risks of Improper Use: Using a lap board as a restraint increases risks of physical deconditioning, pressure sores, and psychological distress.

• Check the Care Plan: All assistive device use should be documented in the resident's care plan and regularly reassessed.

• Explore Alternatives: Many effective alternatives, such as specialized seating or increased engagement, can reduce the need for restrictive measures.

Understanding the Restraint Debate: Function vs. Freedom

In senior care settings, devices like lap boards are often used to enhance a resident's quality of life and independence. They can provide a stable surface for meals, activities, or positioning support. However, their use is heavily regulated, and caregivers must be vigilant to ensure the device is not inadvertently functioning as a physical restraint.

The Critical Factors: Intent and Easy Removal

The distinction between an assistive device and a restraint hinges on two primary factors: the intent behind its use and the resident's ability to remove it independently.

Intended Use: Assistance vs. Restriction

• Assistive Device: The purpose is to aid the resident in daily activities. For example, a lap board used as a tray for eating, reading, or playing games is assistive. It facilitates an activity the resident wishes to perform.
• Restraint: The purpose is to restrict a resident's movement. If the lap board is used to prevent a resident from rising from their chair due to staff convenience or as a form of behavior management, it functions as a restraint.

Easy Removal: The Resident's Control

• No Restraint: The resident must be able to remove the lap board themselves in the same manner it was applied. If it's a simple, unbuckled tray that can be pushed away, and the resident has the cognitive and physical ability to do so, it is not a restraint.
• Restraint: The moment the device's design or attachment makes it difficult for the resident to remove, it crosses the line. This includes trays with ties, belts, or other fasteners, or even a swing-away tray that a cognitively or physically impaired resident cannot operate. A tray that pins a resident into a chair by placing the chair against a wall also constitutes a restraint.

Potential Benefits of Using Lap Boards Appropriately

When used correctly and not as a restraint, lap boards can offer several benefits for seniors and individuals with limited mobility:

• Enhanced Independence: A stable surface allows residents to engage in activities like eating, reading, or using a tablet independently, fostering a sense of control and self-sufficiency.
• Improved Positioning: For residents with poor trunk control or posture, a lap board can provide mild support to maintain an upright position, preventing slumping and improving comfort.
• Safety for Activities: A non-slip lap board can prevent spills and messes while a resident is eating or drinking, ensuring safety and dignity during mealtimes.
• Cognitive Stimulation: The board provides a dedicated space for puzzles, crafts, and other cognitive activities, promoting mental engagement and reducing boredom.

Serious Risks of Improper Restraint Use

Using a lap board as an improper restraint, whether intentionally or not, can lead to severe physical and psychological consequences.

• Physical Deconditioning: Restriction of movement leads to muscle atrophy, weakness, and joint stiffness.
• Increased Fall Risk: Paradoxically, restricting a resident's movement can increase their risk of falls when they eventually attempt to overcome the restraint.
• Pressure Injuries: Prolonged immobility can lead to pressure sores and other skin integrity issues, which are difficult and painful to treat.
• Psychological Distress: Being confined can cause fear, anxiety, frustration, anger, and agitation, leading to worsened behavioral symptoms and a decline in mental health.
• Regulatory Penalties: In regulated facilities, improper restraint use can result in federal citations, fines, and legal action. The Centers for Medicare & Medicaid Services (CMS) is very clear on its definition of a physical restraint.

The Importance of the Care Plan

Any device used to assist a resident must be integrated into their person-centered care plan. This plan should clearly state the purpose of the device (e.g., providing a surface for meals) and include documentation that the resident can remove it easily. Regular reassessment is also crucial to ensure the device is still appropriate for the resident's changing needs.

Assistive Device vs. Physical Restraint

This table clarifies the key differences in how a lap board's function is interpreted in a care setting.

Factor	Assistive Use (Not a Restraint)	Restraint Use (Requires Justification)
Intent	To provide a stable surface for activities like eating or reading.	To prevent the resident from standing up or leaving their chair.
Removability	Resident can easily and intentionally remove it on their own.	The resident is unable to remove it easily or intentionally.
Attachment	Not attached to the chair or resident in any restrictive way.	Fastened with straps, buckles, or other ties that restrict mobility.
Positioning	Facilitates comfortable and safe posture for activities.	Holds the resident in place against their will or ability to move freely.
Duration	Used only during specific activities and removed afterward.	Left in place for extended periods, restricting movement unnecessarily.
Documentation	Included in the care plan as an aid, with regular review.	Requires comprehensive medical justification, assessment, and physician's order.

Alternatives to Restraints

For caregivers seeking to avoid using a lap board as a restraint, numerous person-centered alternatives can achieve similar outcomes without compromising a resident's freedom.

1. Proper Seating Assessment: A thorough evaluation by a therapist can determine the right wheelchair or seating system to provide stability and support, making a restrictive lap board unnecessary.
2. Increased Staff Presence and Engagement: Having more staff available for supervision, conversation, and redirection can address the underlying issues contributing to unwanted behavior.
3. Individualized Activities: Providing meaningful, engaging activities can reduce agitation and a resident's desire to stand or wander inappropriately.
4. Low Beds and Floor Mats: For residents at high risk of falling, using a bed that can be lowered to the floor, combined with fall mats, can mitigate the risk of serious injury.
5. Motion-Activated Alarms: These can alert staff when a resident begins to stand, allowing for timely intervention without physically restricting them.
6. Environmental Modifications: Changes to the environment, such as proper lighting and removal of obstacles, can reduce agitation and fall risk.

Conclusion: Prioritizing Dignity and Choice

In conclusion, whether a lap board is considered a restraint is not a simple yes or no answer. It is a nuanced issue determined by the intent behind its use and the resident's ability to remove it. When used as an assistive device to promote independence, it is a valuable tool. However, if it prevents a resident from rising or moving freely, it becomes a physical restraint with serious ethical and legal implications. Healthcare regulations and person-centered care philosophies emphasize prioritizing resident dignity, autonomy, and the use of least-restrictive interventions. Caregivers and facility staff must undergo continuous training to understand this critical distinction and ensure devices are used to empower residents, not to restrict them.

CMS guidance on restraint use

Frequently Asked Questions

Does a physician's order allow a lap board to be used as a restraint?

While a physician's order is necessary for restraint use, it does not automatically make the use of a lap board as a restraint acceptable. The restraint must be medically justified, least restrictive, and used only as a last resort, with proper monitoring and documentation.

Can a lap board attached with Velcro be considered a restraint?

Yes, if the resident cannot easily remove the Velcro fastener themselves. The determining factor is the resident's ability to intentionally and independently remove the device, regardless of the attachment method.

What is the difference between a lap board and a lap buddy?

A lap board is typically a hard or padded tray, while a lap buddy is often a soft, cushioned device. However, both can be considered a restraint if they restrict a resident's ability to rise from a chair and cannot be easily removed.

What if a resident with dementia cannot remember how to remove the lap board?

If a resident has a cognitive impairment and cannot remember or physically manage to remove the lap board, it is considered a restraint because they lack the ability to exercise their freedom of movement. In such cases, alternatives should be prioritized.

Is it okay to use a lap board to prevent a resident from falling?

No, using a lap board to prevent falls is considered improper restraint use. Research has shown that restraints do not prevent falls and can lead to more severe injuries when falls do occur. There are safer, less restrictive fall prevention strategies.

How often should the use of a lap board be reviewed?

The care plan for a resident using an assistive device should be regularly reviewed by an interdisciplinary team. For devices that risk becoming a restraint, continuous assessment is needed to ensure it remains the least restrictive option and serves a valid, non-restraint purpose.

What is the consequence of using a lap board improperly?

Improper use of a lap board can violate a resident's rights and lead to physical harm. For a regulated facility, this can result in severe citations, fines, and legal liabilities. Caregivers can also face professional and legal consequences.