MAUDE Adverse Event Report: MEDSORB DOMINICANA, S.A. NEURO-SP-1/2X1/2"-STRL 20/CS; GAUZE/SPONGE, INTERNAL

Model Number	30-054
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/08/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A user facility reported, "the one patty that was used had one of the rfid green strips come off." this has been updated to x-ray green strip as there is no rfid strip in the neuro sponge.Deroyal industries requested return of the device but it was not available.A supplier corrective action request (scar) will be issued to the supplier.This investigation is not complete at this time.No further information is available at this time.We will provide follow-up report when additional information becomes available.
Event or Problem Description
A user facility reported, "the one patty that was used had one of the rfid green strips come off." this has been updated to x-ray green strip as there is no rfid strip in the neuro sponge.
Additional Manufacturer Narrative
A user facility reported, "the one patty that was used had one of the rfid green strips come off." this has been updated to x-ray green strip as there is no rfid strip in the neuro sponge.Deroyal industries, inc.Requested return of the device, but it was not able to be returned.Deroyal reviewed the work order of the device and no issues were found.An inventory check was also performed on one case of the neurosponges.All strips were found to be attached and no other issues were found.Because this is a purchased part, deroyal did not have a risk analysis to review.A complaint to sales ratio was conducted between may 2023 to may 2025 and found to be (b)(4).A supplier corrective action request (scar) will be issued to the supplier, (b)(4).The supplier reviewed the device history record (dhr) and reviewed a previous similar complaint.Due to the previous complaint, it was noticed that when material thickness variations would occur, the production associates would adjust the horn clearance but fail to verify if the adjustment was within the specified parameters.Within the previous complaint, corrective actions were taken, but this lot was manufactured prior to the implementation of those actions.Root cause: because the sample was not able to be returned, the specific root cause was not able to be determined.However, with the previous complaint, a potential root cause would be that when material thickness variations would occur, the production associates would adjust the horn clearance but fail to verify if the adjustment was within the specified parameters.Corrective and preventive actions: corrective and preventive actions were taken on the previous complaint and would also apply to this potential root cause.These actions included: new horns with welder tips that provide more stability to the material.Additionally, work instructions were updated to mandate the verification of the distance between the horn and the anvil.With complaint specifically, a retraining was conducted for all the operators and supervisors on correct weld setup.Deroyal will continue to monitor for trends around this item and issue.This investigation is complete at this time.No further information is available at this time.We will provide follow-up report if additional information becomes available.

• Brand Name: NEURO-SP-1/2X1/2"-STRL 20/CS
• Common Device Name: GAUZE/SPONGE, INTERNAL
• Manufacturer (Section D): MEDSORB DOMINICANA, S.A.; zona franca industrial park; san pedro de marcoris, ; DR
• Manufacturer (Section G): DEROYAL INDUSTRIES, INC.; 1703 highway 33 south; new tazewell TN 37825
• Manufacturer Contact: reagan facemire ; 200 debusk lane; powell, TN 37849 ; 8653622106
• MDR Report Key: 22002779
• Report Number: 1060680-2025-00026
• Device Sequence Number: 9099712
• Product Code: EFQ
• UDI-Device Identifier: 00749756037242
• UDI-Public: 00749756037242
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K791871
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/29/2025

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: 30-054
• Device Lot Number: 24102694
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/08/2025
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 05/12/2025
• Supplement Report FDA Received Date: 08/29/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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