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It comes after police and the healthcare facility where the man was staying investigated a previous assault complaint by the man about the same nurse, which was dropped after the nurse and another colleague denied it had happened.
A later complaint involving the man being dragged across the kitchen into the living room before getting him on the ground and sitting on him, resulted in the nurse losing his job.
Today, a Health and Disability Commission (HDC) investigation found the nurse - who had more than 30 years work experience - in breach of the Code of Health and Disability Services Consumers' Rights for his care of the man residing in a secure facility.
The name of the man, nurse and the facility were not included in the report for privacy reasons.
HDC's investigation findings come more than three years after the assault.
The man and the nurse told HDC different versions of events: the nurse said the man tripped and fell, whereas the man said the nurse pushed him.
It was uncovered that the man was on the floor, the nurse sat on the man's body and bounced on him, and did not remove himself promptly from this position. The nurse did not document the man's fall or report the incident.
Deputy Health and Disability Commissioner Rose Wall was critical of the "unreasonable restraint", saying "the nurse's conduct is wholly unacceptable".
"Especially in the case of such a vulnerable consumer," Wall said.
The report detailed that the complaint only came about after the man told another nurse.
"He reported that he has been afraid to lay a complaint because he's scared of
what [the nurse] would do if he found out," the other nurse said.
That nurse reported this conversation to the charge nurse manager (CNM).
As a result of the HDC investigation, the deputy commissioner recommended that the nurse's employer, the DHB, provide evidence of recent training to staff on incident reporting.
It also advised an audit of incidents reported over the last three months to ensure that incidents had been documented appropriately; and review its protocols for staff who notice adverse practices.
She also recommended that should the nurse wish to obtain a practising certificate, the
Nursing Council of New Zealand consider his fitness to practise, and that the nurse and the DHB apologise to the man.