The residents, with an average age of 89, were in a form of assisted living at St. Mary's Villa in Humboldt. They were given a week to move out in February because the home needed to make space for 32 other patients with higher medical needs. Those patients lived in part of the facility where structural problems were found.
Ombudsman Kevin Fenwick said in a report released Thursday that the decision to close the area with structural problems was reasonable.
But the deadline for the move and the way it was handled were not.
"When someone tells you that you might have to move in eight days, the impact is significant," Fenwick said in a release.
"When you're in your 80s or 90s, it can be even more so.
"Despite the health region's good intentions and its efforts to compensate for those very short timelines, these seniors and their families went through a very difficult experience that could have been avoided," he wrote. "They felt stressed and disrespected."
The Saskatoon Health Region says it takes full responsibility for not giving residents adequate notice.
Health region president Maura Davies said they should have given the seniors who lived at St. Mary's Villa more time to prepare.
"In hindsight, we should’ve, could’ve done things differently,” she said, adding that they accept the Ombudsman's report in its entirety.
Davies said the health region did a poor job communicating.
“We know that we could have done better, despite the hard work of many of our staff … for that, we truly are sorry,” she said.
Fenwick is making four recommendations. Among them is a suggestion that the Saskatoon Health Region develop policy to guide moves of elderly people. He also said the region should thoroughly review and revise manuals to reflect the lessons learned from what happened at St. Mary's.
"The most important thing here for these residents was the short period of notice, so the most important thing that should happen is engage people who are affected by your decisions while you are in the decision-making process, not once the decision has already been made," Fenwick said at a news conference.
"The regional staff ... made what they thought were good decisions and they thought they were doing the best thing for these residents. But ultimately it was a decision that was made ... 'to' instead of ... 'with.' (It's) inconsistent with best practices models of decision-making for governmental institutions."
The ombudsman noted in his report that the health region was aware of structural problems at St. Mary's months before the final decision was made to move the seniors.
The report says senior health region officials were at St. Mary's in the spring of 2011 to talk about the findings of an investigation into a deadly carbon monoxide leak. Three residents died and dozens of others fell sick when a gas leak in a boiler caused CO poisoning.
That was when officials decided to address problems with linoleum in that part of the home.
A draft engineering report found bigger problems than lifting linoleum. It said the flooring on the unit was deteriorating.
Fenwick said staff had identified seniors who might have to move as early as last December, but didn't want to cause "undue alarm" by sharing information before having all the details.
That meant "the region missed opportunities" to give the seniors and their families advance notice.
The ombudsman said the region used what it calls an incident command process to help staff manage the short time frame when moving the 10 residents became necessary. But that focused staff on meeting the deadline at the expense of the seniors and their families.
The health region helped move the 10 seniors, most of them to a private seniors housing complex.
Even the relocation did not go smoothly. The movers were late, and packing and unloading took longer than expected.
According to the ombudsman's report, one staff member reflected: "It started off bad and it went downhill. If anything could have gone wrong, it did."
Family members complained that the situation was stressful for the seniors. The families said their loved ones were getting the "bum's rush to the door."
Some families also raised concerns that many of the residents were moved to a complex that costs more than twice as much as the villa. They said that cost would probably be impossible for most of the residents who rely solely on their pensions.
— With files from CKRM, CKOM
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