F0726

D

Failure to Monitor Vital Signs and Respiratory Status After Versed Administration

Lebanon, Tennessee Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing staff had and used the competencies and skills necessary to safely administer midazolam (Versed) and monitor residents afterward. Reference materials reviewed by surveyors, including a National Library of Medicine article and the drug’s Black Box Warning, stated that midazolam is a short-acting benzodiazepine used for sedation and anxiolysis, with known risks of profound sedation, respiratory depression, hypotension, respiratory arrest, hypoxic encephalopathy, coma, and death. These sources emphasized the need for monitoring vital signs such as blood pressure, heart rate, and respiratory rate, especially in older patients, and called for continuous monitoring of respiratory and cardiac function. The facility’s LPN job description and nursing services policy required nurses to observe and evaluate residents’ responses to medications, maintain competency, use critical thinking, and perform pertinent medical assessments such as vital signs as ordered or as needed.

The facility issued a memo from the DON stating that Ativan IM was on national back order and that Versed would be used in its place for anxiety/agitation. The memo indicated that Versed is in the benzodiazepine class, FDA-approved for anxiety/agitation in low doses, and that respiratory status would need to be monitored when it was given, instructing nurses to familiarize themselves with the medication. However, the DON did not specify a time frame or parameters for monitoring and acknowledged that no further training was provided beyond this memo. In interviews, the DON stated she would expect staff to monitor for changes in respiratory status and distress but indicated that obtaining vital signs before and after Versed administration would be on a case-by-case basis. The Medical Director stated that staff should monitor using nursing judgment and referenced a three-hour window of monitoring, while an NP and one LPN later acknowledged that residents should have vital signs taken before and after Versed administration and be watched closely for changes in breathing.

For Resident #11, who had dementia, Alzheimer’s disease, major depressive disorder, psychosis, and severe cognitive impairment (BIMS score of 5), a nurse practitioner ordered midazolam 2.5 mg IM one time for increased aggression and agitation after the resident refused oral medications. The MAR showed Versed 2.5 mg IM was administered by an LPN, but the weights and vitals summary for that month showed no blood pressure, heart rate, or respirations obtained before or after the injection. For Resident #12, who had dementia, mood disorder, anxiety disorder, and severe cognitive impairment (BIMS score of 6), PRN Ativan was reported as not effective for increased anxiety and combative behavior, and a new order for midazolam 2.5 mg IM one time for anxiety was obtained. The MAR documented administration of Versed 2.5 mg IM by another LPN, and progress notes confirmed the new order and administration, but the weights and vitals summary showed no vital signs taken before or after the dose. In interview, that LPN confirmed no vital signs were obtained when Versed was administered. These actions and inactions demonstrated that nursing staff did not perform the necessary monitoring and assessments associated with Versed administration for two residents.