Immanuel's Healthcare: Dialysis Care Lapses - TX
Immanuel's Healthcare had no system to track communications from the dialysis center where three residents received life-sustaining kidney treatments three times weekly. The facility's licensed vocational nurse told inspectors the nursing home "did not keep a book of the communications from the dialysis center."
When residents returned from dialysis appointments, forms were placed "either in the purple binder or medical records drop box," the nurse explained. But inspectors found no outstanding dialysis forms anywhere in the facility.
The breakdown in communication created gaps in patient monitoring. The Director of Nursing acknowledged she "could not make the dialysis center send the communication forms back" and said staff would have to call and request forms be faxed if needed.
Three residents traveled to dialysis on a rigid schedule. Two patients went together on Monday, Wednesday and Friday mornings via city bus transportation. A third resident received afternoon treatments before lunch on the same days.
The morning dialysis patients required preparation with breakfast and snacks before their scheduled pickup. Staff checked their access ports - surgically created entry points for dialysis machines - but documentation of post-treatment monitoring proved inconsistent.
A certified nursing assistant responsible for pre- and post-dialysis weights told inspectors her schedule varied. "She was not always in the facility when Resident #2 returned from dialysis treatment," the inspection report noted. Her work schedule "was not always the same."
This scheduling gap meant the facility sometimes missed collecting critical weight measurements that help determine how much fluid dialysis machines should remove from patients' blood.
The Director of Nursing, who also oversaw medical records, told inspectors she had no pending dialysis communication forms waiting to be uploaded into patient charts. She described a pattern where "the dialysis residents were in and out the hospital a lot" and said treatment orders often weren't reactivated when patients returned to the facility.
Responsibility for reactivating orders fell to admitting nurses, creating another potential gap in the care chain.
Staff interviews revealed confusion about monitoring protocols. One licensed vocational nurse said she would document abnormal vital signs in progress notes and notify the Director of Nursing and physician. Another nurse said she checked vital signs when residents returned from dialysis and would document abnormalities.
But the nursing assistant handling weights wasn't consistently present for post-treatment monitoring of one patient.
The facility's physician told inspectors he wasn't responsible for dialysis orders, saying "that was done by the nephrologist at the dialysis center." He acknowledged having "too many residents on dialysis" but said he knew "the facility provided care and treatment as ordered."
During interviews, residents expressed no concerns about their dialysis care. One patient told inspectors he "went to dialysis every time and he did not miss any appointments." He said the dialysis center kept the communication forms and "did not give him one back."
Staff emphasized that none of the three dialysis patients had missed appointments. The transportation schedule was set, and residents took their treatments seriously. Access sites were checked every shift, staff said, with any concerns documented in progress notes.
The Director of Nursing insisted during the final interview that "the facility had a policy related to the dialysis resident care and treatment to the access site" and maintained that "the dialysis residents had not missed treatment or care."
But inspectors found the facility's communication and documentation systems inadequate for tracking the complex needs of patients whose lives depend on regular dialysis treatments. The missing forms and inconsistent monitoring created potential gaps in care coordination between the nursing home and dialysis center.
Federal inspectors cited the facility for failing to ensure dialysis patients received appropriate services and that their conditions were properly monitored and documented. The violation affected some residents and carried minimal harm or potential for actual harm.
The three dialysis patients continued their regular treatment schedule throughout the inspection, traveling by city bus to their appointments while inspectors documented the facility's tracking failures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Immanuel's Healthcare from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
IMMANUEL'S HEALTHCARE in FORT WORTH, TX was cited for violations during a health inspection on September 5, 2025.
But inspectors found no outstanding dialysis forms anywhere in the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.