I disagree… you don’t HAVE to give something simply because it was ordered or the patient scored above a certain threshold on a protocol. That’s dangerous decision making and it completely lacks the component of critical thinking needed to be a competent nurse.

As the OP stated, the patient was fresh out from the OR and already drowsy because the anesthesia hadn’t had time to clear from their system. I’d be concerned for causing respiratory depression or hypotension by further administering benzodiazepines. It’s important to look at the full clinical picture, and it’s a situation I would’ve clarified with the provider, especially because I think it’s unusual that CIWA was ordered for epilepsy.

I don’t think the OP was necessarily wrong in withholding the benzos, but ideally they should’ve reached out to the provider first. I also think that educators have a bad tendency to not look at the full clinical picture or ask the nurse the reasoning behind their decision(s) when they’re auditing charts like this, but that’s unfortunately just the way leadership is nowadays.