Nexus Surgical Partners

FDA Warns of Infection Control Risks From Mattress Covers

In the last two years, the FDA has received 458 reports associated with medical bed mattress covers failing to prevent fluid ingress, posing a significant risk of infection to patients. The reports were filed between January 2011 and January 2013.

In response, the agency has issued a Safety Communication to “Nurses, Caregivers, Infection Control Professional Staff, Risk Managers, Materials Managers, Housekeepers, Biomedical Engineers, Directors of Purchasing, and other health care providers and staff responsible for the purchase, inspection, use, or maintenance of medical bed mattress covers.”

The FDA reports that mattress covers that are worn or damaged from incorrect cleaning or disinfecting procedures are particularly vulnerable to fluid ingress, and the zipper on the covers may also be a contributing factor.

“Medical literature shows that damaged and wet (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 reads.

To minimize infection risks, the FDA has issued recommendations to ensure patient safety. They are:


  • 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.
  • Be aware that it may be difficult to identify damaged or soiled mattresses because mattress covers tend to be dark in color.

Remove and Replace

  • Remove any damaged, worn or visibly stained medical bed mattress according to the healthcare facility’s procedures and manufacturer’s instructions.
  • Immediately replace any medical bed mattress cover with visible signs of damage or wear to reduce the risk of infection to patients.


  • Clean and disinfect undamaged medical bed mattress covers according to the manufacturer’s guidelines.
  • Do not stick needles into a medical bed mattress through the mattress cover.

Develop an Inspection Plan

  • Check the expected life of the medical bed mattress and the mattress cover.
  • Create an inspection plan for all medical bed mattresses in your facility.
  • Contact the medical bed mattress cover manufacturer for any additional questions.

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