"Given her vulnerabilities, the onus was on the health professionals involved in this woman's care to ensure any intervention was carried out with respect, with reasonable care and skill, and with due consideration to her dignity," Wall said.
"The actions of the clinical nurse manager and the manner in which she bandaged this elderly woman's hands and arms to stop her from moving them was unacceptable. The use of this kind of restraint, and the way in which it was implemented, clearly does not align with current best practice."
The woman's hands were bruised and discoloured and her right thumb was in an abnormal position because they weren't applied well and the clinical nurse manager didn't use reasonable care, she said.
The woman was then not monitored or reviewed, which meant she suffered unnecessarily as the harm was not identified until the following morning, and her family was not informed, Wall said.
"Communication with the woman's family should have occurred to facilitate the provision of health services that respected her social needs, values, and beliefs."
Wall did not name the DHB involved, saying she did not find them to be in breach of the code of disability services consumers' rights.
She recommended the DHB provide an apology to the woman's family and supply evidence that changes made and training given to nursing staff have been effective.
The DHB was also urged to consider recommendations made by the Health and Disability Commissioner's independent nursing adviser.
Wall recommended the clinical nurse manager provide a written apology to the family and show evidence of completing training on the use of restraints and the management of actual or potential aggression.
She noted the manager has undergone further training and the DHB has made changes including more staff training following an internal review.
"Complaints offer a significant learning opportunity, to reflect on how care could be improved. I am pleased to see the nurse has made changes to her practice and undergone further training."
