MAUDE Adverse Event Report: RESPIRONICS, INC. DREAMSTATION GO AUTO W/BT; VENTILATOR, NON-CONTINUOUS (RESPIRATOR)

Model Number	HKG502S15
Medical Device Problem Code	Degraded (1153)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/26/2021
Type of Reportable Event	Malfunction
Event or Problem Description
A continuous positive airway pressure (cpap) was returned to a third party service center for service.There was no report of patient harm or injury.During evaluation at a third party service center, the sound abatement foam was found to be degraded.The manufacturer's investigation in on-going.A follow-up report will be submitted when the manufacturer's investigation is complete.
Additional Manufacturer Narrative
The manufacturer previously reported an allegation of an issue related to sound abatement foam.This action was reported to fda per 21 cfr part 806.The device will be corrected per res 88058.

• Brand Name: DREAMSTATION GO AUTO W/BT
• Common Device Name: VENTILATOR, NON-CONTINUOUS (RESPIRATOR)
• Manufacturer (Section D): RESPIRONICS, INC.; 1001 murry ridge lane; murrysville PA 15668
• MDR Report Key: 11901936
• Report Number: 2518422-2021-01614
• Device Sequence Number: 19771819
• Product Code: BZD
• UDI-Device Identifier: 00606959050181
• UDI-Public: 00606959050181
• Combination Product (Y/N): N
• Initial Reporter Country: IN
• PMA/510(K) Number: K131982
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: foreign,other
• Initial Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 08/25/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Lay User/Patient
• Device Model Number: HKG502S15
• Device Catalogue Number: HKG502S15
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 05/26/2021
• Supplement Date Received by Manufacturer: 08/16/2021
• Initial Report FDA Received Date: 05/28/2021
• Supplement Report FDA Received Date: 08/25/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: RES 88058
• Patient Sequence Number: 1