An elderly woman with worsening dementia was attacked and left bruised by a healthcare assistant while she was in hospital for specialist care.
The 82-year-old was admitted to an unnamed private hospital's dementia unit respite care in 2013 but during her nine-day stay she sustained numerous injuries.
Her file was not adequately detailed with her medications, nor did it contain details about the woman's behaviour or preferences.
On the sixth night of her stay, a healthcare assistant physically abused the woman by grabbing her arms and slapping her legs which caused finger-mark bruises.
The incident was witnessed by another healthcare assistant but it was not reported.
The elderly woman complained she was attacked by a staff member and "bashed on the knee" but the completed incident report had no note of the incident except she had bruises on her upper arms.
She was taken to another hospital by her family and later discharged back into their care while the health care assistant was later fired following an internal investigation.
The matter has since been referred to the police.
Deputy Health and Disability Commissioner Rose Wall said there was a marked imbalance of power between the woman and the healthcare assistant.
"People with dementia can be particularly vulnerable to abuse, and the fact that the person has dementia can make it harder to establish whether abuse is taking place, and by whom," she said.
"Ms C's (healthcare assistant) response to the situation was clearly inappropriate."
"To act in this way towards an elderly and vulnerable patient is a very serious departure from fundamental professional and ethical standards, and is clearly unacceptable."
The deputy commissioner also found the hospital in breach of the HDC Code of Rights because its initial care plan and incident reports did not contain adequate information, the care plan was not updated to take into account changes in the woman's condition, and the hospital's medication management was sub-par.
Furthermore, hospital staff failed to assess the woman's injuries adequately, or manage them appropriately.