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

Model Number	GBG502S15
Medical Device Problem Code	Degraded (1153)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/16/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This mdr is being submitted as part of a batch submission of complaints that were reassessed as reportable foam degradation complaints; discovered as part of a retrospective remediation review.
Event or Problem Description
A ventilator was returned for service.There was no harm or injury reported.During the evaluation at the manufacturer's service center, the sound abatement foam was replaced for repair.This issue was reported to the fda per 21 cfr 806.The device will be corrected per res 88058.
Additional Manufacturer Narrative
G.6 section incorrectly marked 30 days and initial including 15 days, which should marked as 30 days and initial only in this follow up report.G.2 section incorrectly marked in previous report, which is correctly marked as consumer and foreign in this follow up report.
Event or Problem Description
The manufacturer received information alleging an issue related to cpap device's sound abatement foam.During device evaluation faulty blower and foam was observed.There was no report of patient harm or injury.This issue was reported to the fda per 21 cfr 806.The device will be corrected per res (b)(4).
Additional Manufacturer Narrative
The manufacturer previously reported incorrect data in section b2, which was rectified in previous follow-up.Section e1 was incorrectly reported in the previous report, which correctly updated in this follow up report.Section g2 was marked incorrectly in previous report as consumer and company representative.The report should have been sent for foreign and consumer in g2.Section g6 was marked incorrectly in previous report as 15days.The report should have been sent for 30 days and initial in g6.

• Brand Name: DREAMSTATION GO AUTO CPAP
• Common Device Name: VENTILATOR, NON-CONTINUOUS (RESPIRATOR)
• Manufacturer (Section D): RESPIRONICS, INC.; 1001 murry ridge lane; murrysville PA 15668
• Manufacturer (Section G): RESPIRONICS, INC.; 1001 murry ridge lane; murrysville PA 15668
• Manufacturer Contact: kimberly shelly ; 6501 living place; pitsburgh, PA 15206 ; 2673970028
• MDR Report Key: 14132618
• Report Number: 2518422-2022-09543
• Device Sequence Number: 11331923
• Product Code: BZD
• UDI-Device Identifier: 00606959048676
• UDI-Public: 00606959048676
• Combination Product (Y/N): N
• Initial Reporter Country: HK
• 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: Consumer,Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Recall
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/22/2022

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: GBG502S15
• Device Catalogue Number: GBG502S15
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Fifteen-Day
• Initial Date Received by Manufacturer: 10/16/2020
• Supplement Date Received by Manufacturer: 10/16/2020; 10/16/2020
• Initial Report FDA Received Date: 04/18/2022
• Supplement Report FDA Received Date: 04/18/2022; 08/22/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 07/19/2018
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• 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
• Patient Sex: Unknown