An email was sent to staff at a Sydney aged care facility advising them to make sure residents who were restrained weren't easily visible, an inquiry's heard.
After caring for a husband with dementia at home, moving him to a residential aged care facility was meant to provide Lillian Reeves with a much-needed break.
But in the 10 weeks Terry Reeves was at Garden View Aged Care he was physically restrained without consent, allegedly given antipsychotic drugs his family didn't approve and lost the ability to walk unassisted.
Lillian had been caring for him herself before their family made the decision to put him in the western Sydney facility while she went on a holiday.
A royal commission sitting in Sydney on Tuesday examined the use of physical restraints and medication to manage Mr Reeves who's now 72.
Counsel assisting Paul Gray showed the hearing an email sent by Garden View Aged Care clinical nurse educator advising staff to keep residents who needed to be restrained out of sight.
"It doesn't look nice when visitors walk in and see resident being restrained," it said.
During questioning by Mr Gray, the Merrylands facility's director of nursing, Kee Ling Lau, admitted Mr Reeves had been physically restrained before consent was sought from his family.
"Yes, without authorisation but I hoped the staff would have assessed him and ... based on the assessment they would have applied it," she told the commission.
Kenneth Wong, a GP who assessed Mr Reeves when he arrived at the facility, told the commission physical restraints should only be used when there was no other alternative.
Dr Wong revealed there was no time limit on their use at the facility and it was up to the nurses' judgment.
The commission earlier heard from Mr Reeves' daughter, Michelle McCulla, who said in the short time her dad lived at the facility her family saw him restrained 30 times.
They had been advised it would only happen during peak periods or as a last resort and never for long.
Ms McCulla recalled one visit seeing her father in a small room with a line of chairs in which residents were restrained with lap belts.
"I crouched down in front of my father, he was asleep, he had his head on his chest, eyes closed, drooling," she said.
On another occasion, she found him asleep with a piece of meat lodged in his throat and he was "soiled quite badly, all the way up his back".
A distraught Ms McCulla told the inquiry her father didn't wake as she reached down his throat to remove the food.
She was convinced nurses had given him the antipsychotic medication Risperidone, to which he didn't respond well, but they assured her they hadn't.
"I was told this is what happens when they come into a home and that he is just tired," she said.
"I left that day in tears, we couldn't feed him, we couldn't wake him."
Ms McCulla told the inquiry over time she noticed her father couldn't walk unassisted and was very unsteady on his feet.