Mabel Garcia had just said good morning to her grandson, who slept overnight in a chair near her hospital bed. Then suddenly, she stopped talking.
The right side of her face sank and her eyes fluttered as nurses at Memorial Hospital of Texas County in Guymon, Oklahoma, surrounded her bed. Her mouth gaped open.
"Mabel. Mabel. Can you look at me?" a nurse asked.
Her grandson, Fabian Daniels, used his cellphone to record while hospital employees attempted to get the 67-year-old to respond. He quickly texted his mom, who was at work waiting to hear how Garcia was feeling a day after she checked in with dizziness and chest pains.
"Mima is not talking to them right now," the 17-year-old wrote early that Thursday morning in April 2019.
"Why?" asked his mother, Jennifer Daniels.
"They don't know. She was talking a little bit ago," he replied.
Healthcare professionals at the hospital, which sits in a remote part of Oklahoma known as No Man's Land, determined that they couldn't provide the "higher level of care" Garcia required, according to medical records reviewed by The Frontier and ProPublica. They called an ambulance to drive her to an airstrip where a medical helicopter took her about 130 miles south to a hospital in Amarillo, Texas.
More than 3.5 hours after her initial symptoms, doctors at BSA Hospital in Amarillo found that Garcia had a stroke. They gave her Activase, a time-sensitive medication that helps break down clots, but told her daughter that too much time had elapsed since her initial symptoms.
Garcia had suffered brain damage.
"They said the result would not have been as bad if she had been treated sooner," Jennifer Daniels said, recalling her conversation with doctors. (BSA Hospital did not return requests for comment.)
Surrounded by 2,000 square miles of prairie and dotted with small farming communities, Memorial Hospital is among at least 13 facilities in the state that hired private management companies based on promises of financial turnarounds but were instead left scrambling after sinking deeper into debt, an investigation by The Frontier and ProPublica found.
The hospital cycled through four management companies in 5 years, including Synergic Resource Partners, which managed the facility until days after Garcia arrived. Memorial Hospital laid off about half of its staff, shuttered its obstetrics department, and stopped stocking lifesaving drugs to treat strokes, heart attacks, and rattlesnake bites in the 1.5 years Synergic Resource Partners was in charge, according to interviews and records.
Records do not show whether hospital staff members diagnosed Garcia with a stroke or if they determined that she needed Activase. But even if they had, the hospital didn't have the medication, according to Maria Puebla, the drug supply room manager, and Emmanuel Barias, MD, who served as the hospital's interim CEO from late April 2019 to March 2020. They said the hospital ran out of its supply in March 2019.
The hospital's board has since cut ties with the company and taken control itself. Even with new leadership, efforts to repair years of financial strain under multiple management companies have grown increasingly difficult as the hospital faces a new challenge: The county has the highest rate of COVID-19 cases in Oklahoma. Patients have been sent to other hospitals because the facility in Guymon does not have the staff to handle the increased numbers.
Rochelle Leyva, chairwoman of the hospital board, blames a parade of management companies for the facility's financial troubles. "I don't think they've been here for the right reasons," Leyva said.
Doug Swim, the owner of Synergic Resource Partners, declined interview requests.
Barias said he approached the supplier to try to purchase more Activase after taking the helm of the hospital but was told he would first have to pay off outstanding debts. The hospital could not afford to purchase the medication until July, Barias said.
Months earlier, in January 2019, state health inspectors released the findings of an investigation that revealed the hospital failed to provide basic emergency care, turning away one stroke patient because it did not have Activase. In response to the investigation, hospital officials said the facility kept Activase in stock but only used it for heart attack patients.
Officials pointed out that as a low-level stroke center, the hospital is only required to assess, resuscitate, and provide emergency intervention for stroke patients before transferring them to hospitals with more resources. But Memorial Hospital used Activase for stroke patients before falling behind on payments and is again using the medication now that the facility is controlled by the county government.
Hospital officials declined to talk specifically about Garcia's case, but Martin Bautista, MD, the current chief of staff, said keeping the medication on hand to treat stroke patients is vital to achieving the hospital's mission, which is providing access to critical care. Transferring patients to a larger facility can take more than an hour. The wait, he said, could cause permanent damage to the brain.
"That's the difference between a for-profit and a not-for-profit community hospital," Bautista said. "If we can't serve our elderly people who've paid taxes all their lives, then we shouldn't be open."
Mounting Bills and Cuts to Services
Synergic Resource Partners was hired to run Memorial Hospital in October 2017 after Swim, an attorney from Oklahoma City, promised leaders in the meatpacking town of nearly 11,000 people that he could inject up to $2 million into the hospital's coffers, according to former board members and Mike Boring, Texas County's district attorney.
The offer from Swim, who had never run a hospital, arrived just as county officials were considering closing the facility. Across the country, rural hospitals face dwindling numbers of patients, shortages of doctors and nurses, and low reimbursement rates from the federal government that place them at high risk of closure. Nearly 130 rural hospitals, including nine in Oklahoma, have closed in the past decade.
Memorial Hospital racked up at least $2.4 million in unpaid bills under previous management companies, financial information reported to the Medicare program shows. The debt was likely higher, according to Boring, but he said the board had no way of knowing the exact amount because the previous management company, Little River Healthcare, walked away with financial records before filing for bankruptcy in 2018. Attempts to reach a representative of the company were unsuccessful.
The hospital board hired Synergic Resource Partners without a background check or seeking any proof that the company was financially equipped to take control of the hospital, Boring said.
Oklahoma law doesn't require background checks on hospital management companies, leaving the task of vetting them to local governing boards that have repeatedly failed to check their qualifications or financial stability, as The Frontier and ProPublica have reported.
After 5 months managing Memorial Hospital, Synergic Resource Partners went a step further. The company purchased the operating license from the Texas County hospital board for $100 in April 2018.
The hospital cut services and fell further behind on payments for medical supplies and drugs under the company's management and ownership, according to interviews and financial records.
In October 2018, Synergic Resource Partners cut costs by closing the obstetrics department, forcing pregnant women to seek care more than 40 miles away in Liberal, Kansas. Hospital administrators told the Guymon Daily Herald that the hospital lost $1 million in a year by operating the department.
The company also conducted a series of layoffs, reducing the number of employees from 191 to 92 during the time it controlled the hospital, according to minutes from a board meeting this year.
"People were fired because they could not be paid anymore. Fired without cause, without warning," Barias said.
Synergic Resource Partners and another company owned by Swim, Solutions Healthcare Management, were paid more than $461,000 for services invoiced in the first 5 months of managing the hospital, according to financial records. A third company, Solutions on Staff, which provided medical personnel to the hospital and was also owned by Swim, received more than $192,000. Records do not specify whether the payments were reimbursements for employee payroll. Details on the company's profits or losses after it assumed ownership of the hospital are not available.
By late March 2019, Swim began sending a series of emails that gave the hospital board 4 days to choose from a set of options: Take back ownership or leave the hospital in the company's hands and prepare for possible closure.
Swim said in an email that his company had been unable to secure bank loans and investors because of the hospital's financial position. Under Swim's preferred option, Synergic Resource Partners would transfer ownership of the hospital to the governing board but would continue to manage it for a monthly fee of $60,000. The board would also pay the salaries and benefits of employees who worked with the hospital but were employed by another company owned by Swim.
The hospital board instead sued Synergic Resource Partners, claiming the company failed to pay rent on the building, salaries, and other bills. Days later, the board and Swim settled the lawsuit. The board agreed to assume responsibility for the hospital's outstanding debts, including some that were incurred under Synergic Resource Partners, in exchange for the operating license. At the same time, the board cut ties with the company.
"I think he and we all recognized this time that the deal just wasn't going to work because he didn't have the capital that it was going to take to make it work," Boring, the district attorney, said of Swim.
Guymon Fire Chief Grant Wadley, who runs the city's ambulance service, said cuts to services and reductions in staffing under the company have made it hard for the hospital to recover.
Wadley recalls rushing a stroke patient, who was not Garcia, to the airport after learning that the hospital ran out of Activase. In at least three other cases, emergency responders delivered babies on the side of the road while driving pregnant mothers to Kansas because the hospital closed its obstetrics unit. While some births have taken place in Guymon's emergency department, Wadley said EMS responders attempt to take patients to Liberal where they can receive specialized care.
Wadley said he still hesitates when considering where to take patients.
"We will take them there, but we kind of grit our teeth and hope and pray," Wadley said.
Struggling to Recover
Memorial Hospital was still recovering from cuts when the coronavirus pandemic struck the town.
The hospital board opted against selecting another management company. Instead, it hired Nancy Schmid, who previously worked as a hospital administrator in California, as its full-time CEO. Schmid declined an interview request.
It also began rehiring staff after voters last year approved a sales tax increase that allowed the hospital to secure a $3.5 million loan. But the shortage of doctors and nurses stemming from layoffs under Synergic Resource Partners, the absence of an intensive care unit, and an inadequate ventilation system to stop the spread of the disease left the hospital ill-prepared to handle a spike that developed largely from the Seaboard Foods pork processing plant in Guymon. About 640 of the plant's 2,500 employees tested positive for the virus. As of June 30, one in every 20 residents in Texas County had tested positive for COVID-19, compared with one in every 190 residents in Tulsa County, which had the highest number of cases in the state.
Hospital officials said financial constraints forced them to make the difficult decision not to treat COVID-19 patients.
"The hospital suffered greatly, and we continue to pay for it," Bautista said about the previous management.
Guymon Mayor Sean Livengood, who declared a state of emergency on March 30, said the hospital's inability to treat COVID-19 patients placed a strain on the town. Emergency responders from Guymon, supplemented by ambulances staffed with crews from other parts of the state, were forced to transfer patients with symptoms to larger, better-equipped hospitals more than 100 miles away.
"It's worrisome that you would have to go maybe an hour to Dumas, Texas, or two hours to Amarillo to get appropriate treatment," said Livengood, who also works as a production manager for Seaboard. "You don't want to have to deal with that if you're sick and in dire need."
On a Wednesday morning in late April, Ricardo Mora woke up at his home in Guymon with chills and a fever after testing positive for COVID-19. He rushed to his doctor's office where he logged a temperature of 103.7 degrees and low oxygen levels. A chest x-ray revealed Mora had pneumonia in both lungs.
He needed emergency care, his doctor said. Because the Guymon hospital was not accepting COVID-19 cases, Mora and his wife, Teri, drove 2 hours to Amarillo, where he was turned away because his conditions were not considered severe enough for hospital admission.
The Moras drove to Oklahoma City, where their daughter lived. A day after arriving, Mora woke up struggling to breathe. Teri rushed him to OU Medical Center, which was about 10 minutes away. He spent the next 5 days on oxygen.
"We're the lucky ones," Teri Mora said. "We knew how to advocate for ourselves and which questions to ask. Many people do not."
In June, Memorial Hospital converted its closed maternity wing into a temporary unit that could treat COVID-19 patients, with the help of $1.3 million in federal emergency funds through the U.S. Army Corps of Engineers. But the hospital doesn't have employees to staff the unit, and it might need to rely on volunteer healthcare workers from other parts of the state, officials said.
"We're doing everything we can now to prepare in case we have another uptick in cases, now that we have more resources," Leyva said, but she added that it will take time for the hospital to fully recover.
'We Lost a Big Part of Her'
After the stroke, Garcia could no longer do the things that gave her joy. She lost the ability to speak, couldn't host family gatherings at her home, and the former Head Start teacher was unable to help her grandchildren with their homework.
"Those last months after the stroke, it was like having a different person around," her daughter Jennifer Daniels said. "It felt like we lost a big part of her that day."
Garcia died from acute kidney failure tied to heart problems 3 months later. Daniels now avoids the 10-minute drive to Memorial Hospital when she needs healthcare. She'd rather drive 45 minutes to Kansas.
"I am glad for the community that the hospital is there," Daniels said. "It also keeps people employed."
But Daniels worries about cutbacks at the hospital, which lacks a surgical unit and a critical care unit. And she still struggles with the care provided to her mother a little more than a year ago.
The hospital has not responded to Daniels's request for a detailed account of her mother's treatment, citing legal reasons.
Daniels spent months wondering why the hospital didn't suggest that her mother go elsewhere when she first checked in and why it took so long to transfer her after she stopped speaking. Now, she mostly tries not to think about it.
"I need to look forward, not backwards, so I can stay all right for my family," she said.
This story was originally published by ProPublica.