Nurses union, Tacoma hospital at odds over pace of replacing mattresses oozing fluid

Story has been updated with additional comment from St. Joe’s and WSNA.

Two months after initial complaints were made about damaged mattresses, a Tacoma hospital says any beds “oozing fluids” have been removed from service as it works to replace them.

A union representing nurses at St. Joseph Medical Center earlier this week called for removal and replacement of any mattress with surface micro-tears following the September discovery of compromised mattresses in the hospital’s labor-and-delivery department.

A damaged mattress surface leaves the bed vulnerable to absorbing blood and other bodily fluids from patients.

The hospital on Thursday said damaged beds have been removed and blamed supply-chain issues for the slow pace of replacement.

Washington State Nurses Association, in a news release this week, described a situation where “blood and other bodily fluids” have leaked from micro-tears in mattresses in the labor-and-delivery department at St. Joseph.

Jennifer Schomburg, president of St. Joseph Medical Center, responded to questions about the damaged mattresses in an emailed statement to The News Tribune.

“St. Joseph Medical Center takes the highest responsibility to ensure the safety and quality of our equipment for our patients,” she said. “Any mattresses that are compromised are immediately taken out of commission and not used for patient care.”

She added, “As a standard process, we regularly inspect all beds after every use when they are cleaned and disinfected, and immediately remove any mattresses from use if they do not meet safety standards.”

Her responses stand in contrast to the scenario described both in WSNA’s release this week and its complaint filed with the state Department of Health on Oct. 7.

A copy of the complaint was shared with The News Tribune with the complainant’s name redacted.

The union this week said that the mattress issue was first reported at the hospital Sept. 8, “and since then, some beds were replaced and others were patched, which didn’t stop the seepage of bodily fluids.”

“This is a patient safety issue that we have been raising the alarm on for two months,” Jayson Dick, WSNA director of labor strategies, said in the Nov. 7 WSNA release. “In order to keep patients and staff safe, any compromised mattresses need to be replaced.”

According to WSNA, the problem was discovered on a mattress after the bed’s occupant had been discharged.

“Recently, nurses in Labor and Delivery at St. Joseph Medical Center in Tacoma noted blood on the mattress of a patient who had been discharged. They later pushed a white washcloth into the mattress cover and blood and body fluids seeped out,” the union said.

WSNA said it seeks to raise awareness of the issue for workers and patients and referred to past warnings from the U.S. Food and Drug Administration about the issue on a national level.

“The problem at St. Joseph Medical Center is something that could be happening at other hospitals, and WSNA wants healthcare workers and patients to know this is a serious problem that needs to be addressed immediately,” the union said in its release.

WSNA also wrote about the issue in its October member newsletter: “Beware and watch out for compromised beds and gurneys. If you find any report them to your manager ... and if it doesn’t get resolved consider filing a complaint with the DOH.”

Before the patching, nurses used “chucks,” an absorbent disposable napkin covered on one side by plastic, which may be placed under a patient, to help prevent risk of exposure.

WSNA on Thursday told The News Tribune that “While chucks do create a barrier between the patient and the bed and may help to prevent exposure, chucks are not secured to the bed and as a result, may slip or move around beneath the patient, becoming displaced. A displaced chuck may no longer be correctly positioned to serve as an effective barrier and exposure may occur.”

Complaint filed with state

The complaint filed Oct. 7 with DOH included a timeline of events, starting with the initial discovery Sept. 8.

Further internal reports were completed on Sept. 12 citing more damaged beds, it said.

By Sept. 18, it says, another report was generated “as more compromised mattresses were identified.”

On Sept. 20, it states, a patching material was being used “to fix some of the mattresses, but the hospital ran out of the patching material. New mattresses have been ordered but there is a 6–8-week backlog for delivery of the new mattresses.”

The complaint added, “As of October 6, a unit worker indicated that to her knowledge, no borrowed or rental beds have been obtained and placed on the unit.”

Frank Ameduri, public information officer with DOH, told The News Tribune via email that it had received “at least one report related to mattresses, but we have no details to share at this time.”

DOH “has no specific rules related to mattresses in healthcare settings,” he wrote, “however we do have requirements for maintaining medical equipment and following appropriate infection controls practices. Someone could file a report based on general health concerns.”

The hospital, in response to questions, told The News Tribune via email, “An approved protocol to patch mattresses was put into place only for situations when it is safe and appropriate to do so, based on the level of damage. Any mattresses that are damaged and therefore unable to be safely patched are immediately removed from the floor.”

It noted, “Due to supply chain disruptions affecting the entire region and industry, we are not able to order replacement beds as quickly as usual. Patching is an interim measure until replacement beds can be delivered.

“Replacement beds have been ordered and are arriving as they are available.”

WSNA took issue with the patching in its complaint: “Patching applied to Labor & Delivery mattresses (as a stop gap repair measure) is not secure and is rolling up around the edges.”

The union told The News Tribune on Thursday that patched beds were still in use in the unit until this past Monday.

When asked whether it had received any word from DOH after filing the complaint, WSNA responded that a DOH official “indicated that the complaint was received and sent to the survey team — and will be reviewed and addressed during the facility’s unannounced routine survey.”

FDA warnings

The FDA, in a posting from 2017, said that from 2011 through 2016 it had received “over 700 reports of a hospital bed mattress cover failing to prevent blood or body fluids from leaking into the mattress.”

The FDA calls for removal of “any damaged, worn, or visibly stained hospital bed mattress according to the health care facility’s procedures and manufacturer’s instructions.”

It also says to “Immediately replace any hospital bed mattress cover with visible signs of stains, damage or wear to reduce the risk of infection to patients.”

In a 2013 safety communication about potential mattress problems, the FDA said, “Fluid ingress may occur if mattress covers 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.”

It added, “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.”

In an email sent Thursday by its media representative, St. Joe’s said it “would like to reiterate that the hospital follows FDA policy on removal and replacement and immediately removes from service any damaged, worn or visibly stained hospital bed mattress.”