MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD VENTED HOSPITAL FULL FACE MASK; MNT

Model Number	RT040
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/08/2021
Type of Reportable Event	Malfunction
Event or Problem Description
A distributor in (b)(4) reported on behalf of a healthcare facility that the seal of a rt040 vented hospital full face mask was separated from the mask base during use.There was no reported patient consequence.
Additional Manufacturer Narrative
(b)(4).Method: the complaint rt040 vented hospital full face mask was not returned to fisher & paykel healthcare (f&p) for evaluation.Our investigation is based on the information and photograph provided by the customer, and our knowledge of the product.Results: visual inspection of the photograph revealed that the seal was partly separated from the mask base.It was further observed that the rt040 mask base and seal connection was covered with adhesive medical tape.It was also noted that the subject device was in use for 30 days.Conclusion: we were unable to determine the root cause of the observed separation.However, it is likely that the excessive use of mask beyond the intended 7 days of use contributed to the reported failure.The rt040 vented hospital full face mask features a mask base, seal, and headgear.The mask seal is inserted into the mask base and is secured with glue.Each assembled mask seal is inspected to ensure it is correctly inserted and there are no unacceptable gaps between the seal and the base.Samples are taken and the mask seals are pulled apart after 24 hours to ensure they meet or exceed the required detachment force before the assembled product can be released.Our user instructions illustrate in pictorial format the correct set-up and proper use of the rt040 vented hospital full face mask.It also states the following: "verify that the therapy device, including alarms and safty systems, have been validated prior to use." "this mask may only be used in a hospital or clinical setting where the patient is adequately monitored by trained medical staff.Failure to monitor the patient may result in loss of therapy, serious injury or death." "this product is intended for use for a maximum of 7 days.Discard according to hospital protocol.".

• Brand Name: VENTED HOSPITAL FULL FACE MASK
• Common Device Name: MNT
• Manufacturer (Section D): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer (Section G): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer Contact: faranak gomarooni ; 173 technology dr.; suite 100; irvine, CA 92618 ; 9494534000
• MDR Report Key: 12791769
• Report Number: 9611451-2021-01277
• Device Sequence Number: 5657741
• Product Code: MNT
• UDI-Device Identifier: 09420012429841
• UDI-Public: (01)09420012429841(10)2101016616(11)200220
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K060044
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility,Distributor
• Initial Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date (Section B): 10/12/2021

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: Health Professional
• Device Model Number: RT040
• Device Catalogue Number: RT040
• Device Lot Number: 2101016616
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/12/2021
• Initial Report FDA Received Date: 11/10/2021
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 02/20/2020
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown