F0755

D

Failure to Maintain Required Controlled Substance Records for Midazolam

Lebanon, Tennessee Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain required records for receipt, administration, wasting, and destruction of the controlled substance Midazolam (Versed) obtained from the emergency medication supply (med bank), contrary to its own policies on emergency medications, controlled substances, and pharmacy services. Facility policies required an individual controlled substance record for each resident receiving a controlled drug, including documentation of quantity received, number on hand, time of administration, and nurse signatures, as well as two nurses to witness dispensing and wasting from the emergency supply. Despite these requirements, the facility was unable to produce narcotic sheets or other documentation showing proper receipt and disposition of Midazolam for four residents.

For one resident with Alzheimer’s disease, COPD, CHF, psychosis, and wandering, who had intact cognition and no noted behaviors on assessment, an order was written for a one-time intramuscular dose of Midazolam for agitation. A 1 ml vial of Midazolam 5 mg/ml was pulled from the emergency med bank, and 2.5 mg (0.5 ml) was administered, but the facility could not provide documentation of the medication’s receipt or the disposal of the unused portion. For another resident with cerebral infarction, vascular dementia, and depression, who had moderately impaired cognition and physical and verbal behaviors interfering with care, two separate one-time IM Midazolam orders were written on consecutive days. Each time, a 1 ml vial was pulled from the med bank and 2 mg (0.4 ml) was administered, yet the facility again lacked documentation of receipt and disposal of the remaining Midazolam.

For a third resident with dementia, Alzheimer’s disease, major depressive disorder, and psychosis, who had severe cognitive impairment and no noted behaviors on assessment, a one-time IM Midazolam order for agitation was written, a 1 ml vial was pulled, and 2.5 mg (0.5 ml) was administered, but no documentation of receipt or wasting of the unused medication was available. For a fourth resident with dementia, mood disorder, and anxiety disorder, who had severe cognitive impairment and no noted behaviors on assessment, a one-time IM Midazolam order was written and a 1 ml vial was pulled; however, the MAR showed a higher dose administered than ordered, and the facility could not provide documentation of receipt and reconciliation. A later one-time Midazolam order for this same resident was administered without any corresponding med bank pull, and the DON stated that the nurse had saved the prior Midazolam dose in the med cart for 10 days and then administered it, despite there being no PRN order. Multiple LPNs either did not recall or confirmed that narcotic sheets were not completed, and the DON reported that narcotic sheets were shredded and not retained, leaving no accurate accounting of controlled drug receipt, use, wasting, or destruction for these residents.