MAUDE Adverse Event Report: SPSMEDICAL SUPPLY CORP. A DIV. OF CROSSTEX INTL. ULTRA SENSITIVE EARLOOP MASK W/SECURE FIT MASK TECHNOLOGY

Model Number	GCFCXSSF
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Rash (2033)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The ultra sensitive earloop mask w/secure fit mask technology is made with a hypoallergenic cellulose inner layer and is latex free.The masks were discarded and cannot be returned to crosstex spsmedical for evaluation.The lot number of the masks subject of the reported event was not provided.No additional issues have been reported.
Event or Problem Description
The user facility reported that an employee experienced a rash on their face after wearing an ultra sensitive earloop mask w/secure fit mask technology.The employee was prescribed antibiotics.

• Brand Name: ULTRA SENSITIVE EARLOOP MASK W/SECURE FIT MASK TECHNOLOGY
• Common Device Name: MASK
• Manufacturer (Section D): SPSMEDICAL SUPPLY CORP. A DIV. OF CROSSTEX INTL.; 6789 west henrietta rd; rush NY 14543
• Manufacturer (Section G): SPSMEDICAL SUPPLY CORP. A DIV. OF CROSSTEX INTL.; 6789 west henrietta rd.; rush NY 14543
• Manufacturer Contact: daniel davy ; 6789 west henrietta rd.; rush, NY 14543 ; 4403927453
• MDR Report Key: 18190129
• Report Number: 1319130-2023-00013
• Device Sequence Number: 6662827
• Product Code: FXX
• UDI-Device Identifier: 10732224120062
• UDI-Public: 10732224120062
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 11/22/2023

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: GCFCXSSF
• 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: 10/26/2023
• Initial Report FDA Received Date: 11/22/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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