MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; WC, XW, 20", RDLA, SA, 500 LB

Catalog Number	KX208V21S
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/25/2025
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that one of the rear wheels has a cracked spoke.
Additional Manufacturer Narrative
The customer stated "one of the rear wheels has a cracked spoke"; the customer was unsure of how or when it happened, indicated the unit was not received this way, and reported no injury and that the issue did not occur during use.Medline reviewed the photo provided by the customer; a physical sample was not provided, so only a visual review of the defect could be conducted, and multiple rear wheel spokes appeared to be fractured at the wheel hub.The investigation results were confirmed, and root cause was documented.No product changes were identified that could've contributed to this product failure, no trends were identified for the specified material number and corresponding defect type, corrective/preventive action was not taken, and the division will monitor complaints through quarterly trending.There were no reports of death, serious injury, medical intervention, or follow up care.It has been determined that the reported event could cause or contribute to serious injury if it were to occur again.In an abundance of caution, this is a reportable event.If additional information becomes available this report will be reopened and reevaluated.This medical device report (mdr) is being submitted as part of retrospective review activities, which include review of historical data in accordance with regulations at 21 cfr part 803.The information included in this mdr reflects the information reasonably known to the manufacturer at the time of this retrospective review and submission.

• Brand Name: MEDLINE
• Common Device Name: WC, XW, 20", RDLA, SA, 500 LB
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: daniel soto ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50882707
• Report Number: 1417592-2026-49722
• Device Sequence Number: 9827052
• Product Code: IOR
• UDI-Device Identifier: 00193489179906
• UDI-Public: 00193489179906
• Combination Product (Y/N): N
• Initial Reporter State: SC
• Initial Reporter Country: US
• PMA/510(K) Number: K990463
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Type of Report: Initial
• Report Date (Section B): 09/23/2026

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
• Device Catalogue Number: KX208V21S
• Device Lot Number: 16422100002
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/25/2025
• Initial Report FDA Received Date: 09/24/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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
• Patient Sequence Number: 1
• Patient Sex: Unknown