Over a two year period, the FDA received 458 reports associated with medical bed mattress covers failing to prevent blood and body fluids from leaking into the mattress. Some reports indicate that if blood and body fluids from one patient penetrate a mattress, they can later leak out from the mattress when another patient is placed on the bed. Patients are at risk for infection if they come into contact with blood and body fluids from other patients.
This is most likely to occur if mattress covers, which provide outer protection to a medical bed, become worn or damaged from small holes or rips in the fabric or from incorrect cleaning, disinfecting and laundering procedures. The zipper on the cover may also allow fluid to penetrate the mattress.
Medical literature shows that damaged and soiled mattresses can be a source of contamination during infection outbreaks. The FDA is concerned that fluid ingress from worn or damaged medical bed mattress covers may be widespread and largely under-recognized by health care providers, health care facility staff, and caregivers. The Safety Communication lists several recommendations for inspection and maintenance including:
- Regularly check each medical bed mattress cover for any visible signs of damage or wear such as cuts, tears, cracks, pinholes, snags or stains.
- Routinely remove the medical bed mattress cover and check its inside surface. Once the mattress cover is removed, inspect the mattress for wet spots, staining, or signs of damage or wear. Check all sides and the bottom of the mattress.
- Immediately replace any medical bed mattress cover with visible signs of damage or wear to reduce the risk of infection to patients.
- DO NOT stick needles into a medical bed mattress through the mattress cover.
Medical bed mattress covers, whether water-resistant, water-proof, or water-repellent, may lose their effectiveness over time. The FDA will continue to monitor this issue and keep the public informed if new information becomes available.
See the FDA Safety Alert
See also Medical Law Perspectives, January 2012 Report: Hospital-Acquired Infections: Who Is Liable and Why?