A major provider of disability services and two staff members have been roundly criticised over the way they treated a vulnerable young man.
The case is detailed in a report released on Monday by Health and Disability Commissioner Anthony Hill.
An unnamed 21-year-old with epilepsy and difficulty communicating was receiving respite care in 2010 and 2011 at a NZCare facility for young people with intellectual impairments.
He coughed, provoking a community support worker to push his hand to his mouth, pull him from his chair and push him into his room for time out.
On two other occasions, another community support worker incorrectly administered the medicines he needed to control his epilepsy, and failed to record this and tell others.
Mr Hill says these actions were unacceptable, lacked respect and endangered the young man's health and well-being.
NZCare, which had overall responsibility, also failed, he says.