GILLETTE — A Legacy Living and Rehabilitation Center employee has been charged with felony manslaughter in connection to the death of an 88-year-old dementia patient who was found frozen in an outdoor courtyard in January.
Bernard D. Hale, 57, is charged with criminal recklessness that led to Judith Duvall’s death.
At the time, he was a certified nursing assistant (CNA) at the facility and was terminated following the incident.
Duvall died of exposure and hypothermia after she wandered outside and fell in the snow, where she remained for more than nine hours before being discovered early the next morning.
Hale was booked into the Campbell County Detention Center on Sunday and is awaiting a preliminary hearing on Tuesday. If found guilty of the charge, Hale faces up to 20 years in prison, a fine of up to $10,000, or both.
Kerry Cash, media contact for Campbell County Health, which owns the Legacy facility, did not immediately respond to a request for comment on the arrest or to clarify whether Hale had been a contract or full-time employee at the time of the incident.
After this story was first posted, the Legacy center issued a statement saying it has "cooperated fully" with agencies and investigations and "full cooperation at every level will continue into the future."
The statement also confirmed Hale was a contract employee at the Legacy.
De-Activating Alarms
The manslaughter charge stems from Hale’s failure to meet standards of care that allegedly resulted in Duvall’s death, according to the affidavit of probable cause filed in Campbell County Circuit Court.
On the night she died, Hale was working a 12-hour shift from 6 p.m. to 6 a.m. in charge of Duvall’s memory care unit. Per protocol, CNAs are expected to check on patients every two hours.
Duvall was one of 19 patients in the Cottonwood and Pine units at that time who were identified that day as high risk for wandering. Duvall, in particular, was “an exit-seeking person,” according to a January report by the Department of Health and Human Services Centers for Medicare and Medicaid Services.
Duvall was seen on video surveillance leaving the building and tripping the alarm at 6:51 p.m.
She shuffles briefly before tumbling backwards into the snow about 30 feet from the building, where she struggles to get up for about 20 minutes before becoming motionless at 7:33 p.m., court documents state.
Temperatures that night were between 10 and 35 degrees, according to the National Weather Service, with 2 inches of snow falling the day prior.
Turned Off Alarm
Hale does not respond to the alarm until about 15 minutes later, when he’s captured on video disarming it, the court affidavit says.
Rather than opening the door to look outside for any escaped patients in accordance with protocol, he reportedly turns the alarm off without questioning the other resident standing near the door, it adds.
He then made 15 entries in Duvall’s chart regarding her care, including notes about her oral hygiene, movements, dressing and toileting among others between 7:22 and 7:24 p.m.
After Duvall’s body was discovered, Hale later went back and crossed out several of those entries.
When questioned by police about hearing alarms that night, Hale allegedly reported hearing two alarms — but not at the door though which Duvall exited — and said he’d responded and deactivated the alarms after looking outside and not seeing anything, contrary to video evidence.
Hale further told police he thought he’d last seen Duvall around 9 p.m. and later walked past her closed door around midnight without opening her door out of fear of disturbing her, court documents state.
Based on these behaviors, Hale was charged with manslaughter.
Cited By State
The facility was also cited for failing to adequately protect Duvall, referred to as patient #6, for abuse and neglect that led to her death by allowing her leave the facility without being noticed, according to a January report from the Department of Health and Human Services Centers for Medicare and Medicaid Services.
As a result of the death, the facility fired four employees, including Hale, and implemented new preventive measures and trainings and also stopped taking in new patients.
At a Campbell County Health Board of Trustees meeting in March, hospital administrators vowed to earn back the public’s trust by reducing its reliance on contract workers and instead hiring locally.
Legacy currently has a ranking of one out of five, with one being the lowest, by Medicare.gov.
The ranking considers three categories — health inspections, staffing and quality measures. Based on these categories, the facility scored a one for health inspections, a four for staffing, and four for quality measures.
Over the past three years, the facility had been docked with 16 health citations compared to a national average of 9.6 and 6.1 statewide, according to the ranking.
Second Investigation
A second investigation is ongoing by the Gillette Police Department regarding the overdose death of 66-year-old Rhonda Parker in November 2024, after which an additional staff member was fired.
Records obtained from Gillette police show that the department responded to 17 calls at the facility over the past three years between January 2019 and September 2024.
One of the calls on Sept. 20, 2024, involves a sex offense against a victim who was not a patient which is still pending prosecution, according to Brent Wasson, Gillette deputy chief of police.
Other incidents include an altercation between two memory care patients that was handled internally, six welfare checks, an abuse complaint, vehicle theft and EMS calls, among others.
