A male nurse faces legal action after he used excessive force and made derogatory comments about a mental health patient sitting naked in a bath.
Health and Disability Commissioner Anthony Hill says in a report on Monday the unnamed nurse breached patient rights.
The woman, 76, was a compulsory mental health inpatient at an unnamed district health board.
Mr Hill says she had complex needs and became increasingly agitated one afternoon in November 2010.
After she smeared herself with faeces, she was moved to a bathroom for bathing, becoming increasingly agitated and screaming and crying.
Mr Hill says the male nurse used unreasonable force to remove the woman's clothes, so her arm and hand hit the wall, and then let out the bath water leaving her naked and cold in the empty bath while he made derogatory remarks.
He says no matter how challenging a person can be and how ill they are they are entitled to be cared for appropriately and that did not occur here.
Legal proceedings are pending by Mr Hill's office.