Failure to Obtain Physician Order and Assessment for Use of Lap Buddy Restraint
Penalty
Summary
A resident with diagnoses including dementia without behavioral disturbance, transient ischemic attack, traumatic subdural hematoma, muscle weakness, and unsteadiness was observed using a Lap Buddy device in a wheelchair. The resident's medical record documented severely impaired cognition and a history of multiple falls, with care plans addressing fall risk but lacking any mention of the Lap Buddy. During observation, staff placed the Lap Buddy across the resident's lap to prevent him from standing and falling, as he had previously attempted to ambulate independently. The resident was able to remove the device when prompted by staff, but otherwise it was used to restrict his movement. The facility failed to provide a physician's order, an assessment, or a care plan for the use of the Lap Buddy as a restraint. The resident's electronic medical record did not contain documentation supporting the use of the device, and staff interviews confirmed that the device was used to prevent the resident from standing due to fall risk. The facility's policy requires that restraints only be used with proper medical justification and documentation, which was not present in this case.