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by Christopher Weaver

CHEROKEE, N.C. — When employees at a U.S. Indian Health Service facility here saw a video of their maintenance man disappearing with a 16-year-old patient into a private bathroom, they strongly suspected he was sexually involved with her.

After two staff members questioned the girl, she dragged a chair to the bathroom shower and tried to hang herself from the curtain rod, according to internal documents and people familiar with the September 2016 incident.

Although suspected sexual abuse of minors on Indian reservations is supposed to be reported to law-enforcement officials and social workers, several employees said an IHS manager told them not to say anything.

Months later, the maintenance man, then 47 years old, was told he was fired over the incident—then unfired. He returned to work at the Unity Healing Center, a teens-only residential substance-abuse treatment facility, although by then there was a federal investigation into his conduct. His duties included reviewing safety incident reports, including those about sex abuse.

The IHS, which provides health care for 2.6 million Native Americans, has allowed employees accused of sexual misconduct to continue working and has struggled to meet U.S. requirements for reporting such allegations, a Wall Street Journal investigation found. At Cherokee, no one contacted law enforcement about the maintenance man until about seven months after the incident, and senior agency officials didn’t intervene.

In February, the Journal and the PBS series FRONTLINE reported that IHS pediatrician Stanley Patrick Weber had sexually assaulted young male patients, and that the agency ignored warnings and tried to silence whistleblowers over two decades. The day the Journal/FRONTLINE report was published, the IHS announced a written policy to improve its handling of sexual-abuse allegations.

Yet in interviews in early April, more than two months after the new policy was enacted, employees of the North Carolina facility said they hadn’t yet gotten any details about the new policy or received any training. The Cherokee case suggests that some of the problems that enabled Mr. Weber’s misconduct persist.

Beverly Cotton, the IHS leader of the region that includes North Carolina, said in an interview she thought the subsequent federal investigation of the Cherokee incident had failed to substantiate the misconduct allegations, and that Unity’s policies complied with federal law. “If there was a report of sexual misconduct and a supervisor advised another licensed provider not to report that, both of them hold responsibility,” she said. Law-enforcement officials said the federal investigation is continuing.

A White House task force is investigating the Weber case and the agency’s policies for handling sexual abuse. At a meeting in Albuquerque, N.M., in May, task force members discussed weaknesses they had discovered in the agency’s sex-abuse reporting practices, including confusion among staff members, and a lack of standard policies.

“There is a lack of clarity when it comes to the immediate steps that need to be taken to report suspected child abuse,” said Trent Shores, the U.S. attorney for the Northern District of Oklahoma and a task force leader. He said the task force is examining whether IHS employees understood their legal obligation to report child abuse, and whether any supervisors might have discouraged such reports.

Michael Toedt, the IHS’s top doctor, said the agency has worked in recent months to strengthen its reporting policies, protect whistleblowers and hold accountable people who have failed to protect patients from abuse.

An IHS spokeswoman said the agency is currently tracking six different cases of alleged sexual abuse at its facilities, not including matters between employees such as sexual-harassment claims. The agency is planning to roll out a nationwide training program on reporting abuse later this year, she said.

The IHS has had numerous opportunities over the years to strengthen its procedures for handling sexual-misconduct allegations. IHS officials learned that Mr. Weber, who was convicted of abusing patients in Montana in September and faces another trial over similar allegations in South Dakota later this year, was under investigation about a year before the incident in North Carolina. Mr. Weber is appealing his conviction.

In the 1990s, agency psychologist David Bullis admitted to a supervisor that he had “some exploratory sexual contact” with a teenage patient, but he was allowed to continue working at an IHS facility in New Mexico, according to an appellate-court order in a civil case brought by the alleged victim against the IHS. The case was settled for $300,000, Justice Department records show. Mr. Bullis couldn’t be reached for comment.

On the Colville Indian Reservation in Washington state, there were complaints that an IHS doctor named William Hall had engaged in sexual misconduct involving patients, according to medical board documents. The IHS fired Mr. Hall in 2013, about 20 months after the allegations emerged, the documents show. He is now serving a three-year prison sentence in Florida after attempting to arrange sex with an undercover agent posing as a minor. Mr. Hall didn’t respond to requests for comment.

The Unity center in North Carolina was opened in 1991 on land owned by the Eastern Band of Cherokee Indians. In 2009, a boy named A.J. Long Soldier was admitted to the facility for treatment, according to a lawyer for his estate. He ran away before completing treatment and died of alcohol withdrawal complications several months later, the lawyer said.

In recent interviews, several employees said they reported that an IHS worker spent too much time alone with Mr. Long Soldier, who turned 18 at the facility, in his room. Their allegations weren’t relayed to law enforcement at the time, and the worker later resigned, the employees said.

For some Unity employees, the 2016 incident involving the maintenance man and the teenage girl brought back memories of the Long Soldier one. One employee said in a memo that the 2016 episode thrust the center into “tail spin survival mode.”

The Journal examined what happened by reviewing court records, government documents and emails, and interviewing more than 20 people involved in the matter. The Journal didn’t determine the girl’s name.

The IHS fired doctor William Hall in 2013 after allegations of misconduct arose. He is now serving a prison sentence in Florida. (Florida Department of Corrections)

Unity workers complained to managers that the facility’s maintenance man, Nathaniel Crowe, had been holding hands with and hugging a 16-year-old patient who sometimes referred to him as her boyfriend.

Then staff members saw the security-camera footage showing the two entering a private bathroom and closing the door. A couple of days later, two workers questioned the girl about the incident and letters found in her room.

She denied sexual contact and said she didn’t have a “crush” on the maintenance man. “We were having fun,” the girl told one employee, according to a record of the conversation. “He made me laugh and smile.”

The girl later told employee Selena Crowley that she was upset by the questions about Mr. Crowe. Ms. Crowley said the girl was worried the other workers would show Mr. Crowe letters they had taken from her room.

The next day, the girl’s roommate reported that the teen had tried to hang herself in the bathroom. Workers took her to the local hospital, run by the Cherokee tribe.

Security-camera footage showed IHS maintenance man Nathaniel Crowe disappearing with a 16-year-old patient into a private bathroom.

A Unity administrator banned Mr. Crowe from the residential building. He denied misconduct, saying he was in the bathroom to inspect an electrical outlet and that he thought the girl considered him a father figure, according to his written statement at the time.

In a brief conversation in May outside his current workplace, Mr. Crowe declined to comment.

Federal law requires medical providers, administrators and teachers to report suspected sexual abuse of minors on Indian reservations to social services and law-enforcement authorities. Those who don’t, and managers who obstruct them, can face six months in prison.

Several Unity employees said in interviews that the facility’s clinical supervisor, Tracey Grant, instructed workers not to report the matter.

“She told me, ‘No, I will handle this. Do not contact anybody,’ ” said Tawna Harrison, the teenager’s counselor. “So I didn’t. I deeply regret that.”

Ms. Harrison said she believed she could be fired for disobeying. “It was this unsaid thing where it would be like insubordination,” she said.

Court records reviewed by the Journal indicate that the North Carolina Psychology Board is investigating whether Ms. Grant failed to report alleged sexual misconduct.

Staff members said they never received training on reporting requirements. “We were just told to report to your supervisor,” said Paul von Weckmann, a teacher at Unity until April.

Four days after the suicide attempt, the facility’s governing body discussed the incident at a meeting. That group of senior IHS administrators included Dr. Toedt, then the regional chief medical officer in Nashville, Tenn.

Dr. Toedt ordered Unity staff to perform what is called a root-cause analysis of the suicide attempt. The review took place that week, and Dr. Toedt participated.

The Unity Healing Center was opened in 1991 on land owned by the Eastern Band of Cherokee Indians. (Charles Mostoller for The Wall Street Journal)

A record of the review, which focused on responding to suicide attempts, attributed the incident to a “Resident/staff trust violation” but didn’t otherwise discuss the girl’s interactions with Mr. Crowe.

Dr. Toedt said in a written statement he wasn’t aware of any sexual misconduct at Unity at the time, and that he expected any “high-risk patient situation” at a facility to be immediately reported to higher-ups.

Although the incident wasn’t reported to law enforcement, a report on Mr. Crowe’s conduct, dated Oct. 5, 2016, was filed to regional IHS officials in Nashville. The agency transferred Mr. Crowe to another IHS facility in Cape Cod, Mass., for a month. By the time he returned, the girl had been discharged.

She left behind a hand-beaded necklace for Mr. Crowe with a therapist. The therapist buried it in a desk drawer.

That December, Unity’s CEO at the time, Tiara Ruff, filled out paperwork to fire Mr. Crowe. An Oklahoma-based HR officer finally reviewed the incident report in March 2017, five months after it happened.

“His relationship with a resident who attempted to hang herself is serious,” the Oklahoma HR official, Woodrow Kinney, wrote in an email to a colleague that month. “Plus she is a minor—this should count for something.”

Human-resources officials also discussed the previous discipline of Mr. Crowe for apparent sexual misconduct with a former female staff member in 2013, according to a human-resources record.

A week later, he faced a new allegation in connection with security-camera footage showing him embracing a young woman—neither a patient nor an employee—inside the Unity facility on a Sunday.

According to government documents, another manager, Cynthia Slee, allegedly photographed that footage with her phone and showed it to members of a church she and Mr. Crowe, who is married, both attended. Ms. Slee denied to the IHS that she photographed the footage but admitted discussing the matter with the church members.

By May 2017, officials had decided to fire both Mr. Crowe and Ms. Slee. Mr. Crowe was placed on paid leave, pending his termination.

Around that time, several Unity employees broke ranks and reported the September 2016 incident to local law enforcement and the Cherokee Family Safety Program.

That May 25, Christopher Herndon, a Unity staff member, called the federal Department of Health and Human Services’ Office of the Inspector General and reported that the alleged sexual misconduct had been swept “under the rug,” an OIG record of the call shows.

Mr. Herndon, who joined Unity after the September 2016 incident, said in an interview that he didn’t know if anyone had committed a crime, but he believed he was legally obligated to report the allegations. “There should have been an investigation, and there wasn’t one,” he said.

Unity staff member Christopher Herndon called the Department of Health and Human Services’ Office of the Inspector General and reported that the alleged sexual misconduct had been swept ‘under the rug.’ (Charles Mostroller For The Wall Street Journal)

Early that June, the tribal police subpoenaed Unity in connection with the incident.

A few days later, the Unity CEO, Ms. Ruff, emailed the entire staff, copying in an IHS lawyer: Don’t provide any information to any representatives of “an outside agency.”

An IHS spokeswoman said recently that the lawyers who advised Ms. Ruff were trying to ensure the agency followed patient-privacy rules and weren’t trying to obstruct investigators.

An OIG spokesman said “cooperation of HHS employees with OIG during any investigation is mandated.”

One afternoon later that month, about a dozen OIG agents raided Unity, questioning managers until about 2:30 a.m. Afterward, a government lawyer suggested that the agency shelve plans to fire Mr. Crowe and Ms. Slee until the investigation closed.

In the months that followed, several staff members who had reported the incident to law enforcement either resigned or were fired.

Mr. Herndon, the staffer who had called the OIG, was fired in November 2017. His termination letter said he had been “obstructing management decisions.” Mr. Herndon later filed a whistleblower complaint alleging he was fired in retaliation for reporting the incident. His complaint was rejected.

In March 2018, IHS lawyers and human-resources officials decided not to fire Mr. Crowe. He returned to work the following month, despite the continuing investigation.

Records from that time don’t give a reason for the reversal. However, agency lawyers had deliberated whether Mr. Crowe could win a privacy lawsuit against the agency in connection with the information they said Ms. Slee had shared with church members. Ms. Slee still works at Unity.

Later in 2018, Ms. Ruff, the Unity CEO, was reprimanded by the regional second-in-command, Vickie Claymore, for delays in taking action against Mr. Crowe, among other things. Ms. Claymore wrote that a key management duty was “timeliness in proposing or taking action relative to the dates of alleged offense(s).” Ms. Ruff was reassigned to another post last August.

Mr. Crowe resigned in March 2019. He is running for a seat on the Cherokee tribal council and advanced in a primary election Thursday, according to preliminary results.

Ms. Grant, Unity’s clinical supervisor, told employees in an April 26 training session that the center’s procedures were out of date and the CEO would be updating them soon to reflect the new IHS policy.



—Jennifer S. Forsyth, Dan Frosch and Lisa Schwartz contributed to this article.