An NHS trust in Kent has apologised to a patient and his family after he was restrained on 19 occasions so staff could forcibly treat him.
East Kent Hospitals University NHS Foundation Trust said care for the man "fell far short" of what patients should expect.
The 77-year-old dementia patient was initially admitted to hospital in November last year with a urinary retention problem.
Instead of taking time to calm the man and reassure him, hospital security guards were asked to help ward staff hold him down while he was treated. One incident saw a cloth held over the man's head so nurses could insert a catheter.
The 19 incidents of restraint occurred while the man, who has not been identified, was a patient at William Harvey Hospital in Ashford in November and December 2019.
East Kent Hospitals said it took action after a member of staff witnessed an incident of restraint and raised concerns.
As soon as a member of staff raised their concerns, we reported it to the police and our regulators, suspended a number of staff and opened an investigation, during which we have remained in contact with the patient's family. Changes to dementia care including ward reorganisation, training and recruitment are under way.
The Trust's investigation found a failure to alert senior nurses and/or doctors to the difficulties being experienced in nursing the patient.
The NHS Trust said: "We apologise unreservedly to the patient and his family for the failings in his care, this fell far short of what patients should expect."
A police investigation into what happened was opened and subsequently closed.
One member of staff has been referred to the Nursing and Midwifery Council. East Kent Hospitals is also at the centre of an investigation into its maternity services.