A hospital assessment found the man's mobility needed to be managed due to his high risk of falling, his high level of agitation and restlessness, and his fearfulness and aggression.
The man was released to the secure dementia unit at Ross Home in September, after his wife reluctantly accepted it was no longer safe and manageable to care for him on her own at home.
Prior to his admission, his wife completed a detailed personal history which included a request that no restraints be used in attempts to return her husband to bed.
She also made it clear to one of the nurses that she did not want her husband to be restrained under any circumstances.
But on his first night at the unit, a nurse restrained him in a chair using a lap belt, after which he shredded his pyjamas and acted aggressively.
Two days later, the man's wife visited and found him restrained by a lap-belt. She asked a duty nurse about it but was assured that restraining residents was "against the law".
The patient's wife raised her concerns with staff, but the man was restrained another three times during his two-month stay.
Ms Baker found the procedures required by the national standards for restraining patients - which require all other interventions to be attempted before a patient is restrained as a "last resort" for safety reasons - were not followed.
Ross Home's own restraint policy was also not followed.
Ms Baker noted there was no discussion with the patient's family before the lap-belt was used, despite instructions to call the patient's wife at any time, and the man's agitation increased after he was restrained.
Ms Baker found Ross Home breached the code by failing to comply with the relevant standards.
It also breached the code by failing to have appropriate documentation and incident reporting systems in place, and failing to ensure adequate communication between staff.
"The fact that multiple staff used restraint but did not follow the appropriate procedure indicates systemic failure," Ms Baker said.
The dementia unit's nurse manager, who was also its restraint minimisation co-ordinator, was found to have breached the code by failing to complete and evaluate the man's support plan, or respond appropriately to his falls and aggression.
She also failed to ensure staff received appropriate training in restraint minimisation, and failed to act appropriately in response to her staff restraining the man.
Another experienced nurse, who restrained the man on at least two occasions, was also found to have breached the code.
Ms Baker recommended Ross Home apologise to the man's family and review its restraint procedures.
Her findings noted the home had put in place a number of actions to address the issues, including additional staff training in restraint minimisation.
