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

Model Number	RT041M
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	11/23/2023
Type of Reportable Event	Malfunction
Event or Problem Description
A healthcare facility in germany reported via a fisher and paykel healthcare (f&p) field representative that the seal of a rt041m non-vented hospital full face mask disconnected from the mask frame.There was no patient involvement.
Additional Manufacturer Narrative
(b)(4).The subject rt041m non-vented hospital full face mask is currently en route to fisher & paykel healthcare (f&p) for evaluation.We will provide a follow up report upon completion of investigation.
Additional Manufacturer Narrative
(b)(4).Method: the subject rt041m non-vented hospital full face mask was returned to f&p healthcare for evaluation, where it was visually inspected.Results: visual inspection of the returned masks confirmed that the facial seal was partly separated from the mask base.It was further observed that a continuous bead of glue had been applied to the mask seal.Conclusion: we were unable to determine the root cause of the observed separation as glue had been applied during the manufacturing of the masks.The rt041m 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.Sampling to test seal retention occurs throughout the manufacturing process.Our user instructions illustrate in pictorial format the correct set-up and proper use of the rt041l non-vented hospital full face mask.It also states the following: "operating pressure range: 5 - 25 cmh2o." "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." "in the case of therapy device failure, the use of this mask requires the same level of attention and assistance as in the use of a tracheal tube.".
Event or Problem Description
A healthcare facility in germany reported via a fisher and paykel (f&p) healthcare field representative that the facial seal of a rt041m non-vented hospital full face mask partially disconnected from the mask base.This issue was identified prior to patient use and while still in the original packaging.There was no patient involvement.

• Brand Name: NON-VENTED HOSPITAL FULL FACE MASK
• Common Device Name: CBK
• 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: omid taheri ; 17400 laguna canyon road; suite 300; irvine, CA 92618 ; 8007923912
• MDR Report Key: 18379807
• Report Number: 9611451-2023-01209
• Device Sequence Number: 7600988
• Product Code: CBK
• UDI-Device Identifier: 09420012429865
• UDI-Public: (01)09420012429865(10)2101127140(11)200522
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K083122
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,User Facility,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 11/29/2023

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: RT041M
• Device Catalogue Number: RT041M
• Device Lot Number: 2101127140
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/29/2023
• Supplement Date Received by Manufacturer: 03/19/2024
• Initial Report FDA Received Date: 12/21/2023
• Supplement Report FDA Received Date: 04/18/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/22/2020
• 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