A Dunedin rest home has been found to have breached patient rights by restraining an elderly man with dementia in a chair when he was aggressive.
The events occurred at Ross Home and Hospital, operated by Presbyterian Support Otago.
Deputy Health and Disability Commissioner Theo Baker says the unnamed man was in the secure dementia unit at the resthome for two months in 2010 when he was 84.
Ms Baker says the man was often aggressive, but his family stressed that they did not want him physically restrained.
Despite this, she says staff used a lap-belt often to keep him seated, which made him more agitated.
Ms Baker says a restraint deprives a person of their liberty and should be done sparingly.
"One of the things that has to happen if you're thinking about restraining someone is actually thinking, 'Well have we exhausted all other measures - have we distracted this person, have we taken them away and given them a cup of Milo'.
"One of the key things sometimes when someone's a bit agitated is to let them know that you're listening to them and that they're being heard. That way, you can distract them."
Ms Baker says national standards governing restraint were not followed, there was no discussion with the family and records were not kept.
Presbyterian Support Otago's development director Lisa Wells says changes have been made.
"We have now gone through and made changes to our systems, our processes and our personnel.
"We've had to provide evidence to the HDC to show that that's been done and we've also had to provide ongoing evidence as far as those changes have been concerned so that we can't just change and then let it lapse again."