Skin Failure Shared Interest Group of PAWSIC seal
PAWSIC's First Shared Interest Group

The Skin Failure
Shared Interest Group

A focused professional community for wound care clinicians advancing the recognition, assessment, documentation, and research of skin failure in post-acute and end-of-life care settings.

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About Skin Failure What's Inside Who Joins Leadership
Why This SIG Exists

Skin Failure is Underrecognized and Consequential

Skin failure refers to the deterioration of skin integrity that can accompany severe illness and end-of-life decline. Unlike pressure injuries caused by external forces, skin failure reflects systemic physiologic compromise, and the distinction matters clinically, legally, and for patient care quality.

Despite growing evidence and evolving clinical frameworks, skin failure remains inconsistently defined, documented, and differentiated from other wound etiologies across post-acute settings. The result: unnecessary litigation, regulatory scrutiny, and missed opportunities for appropriate palliative care planning.

The Skin Failure SIG brings together the wound care community to change that.

  • Kennedy Terminal Ulcers (KTU) and end-of-life skin changes
  • Skin Changes at Life's End (SCALE): evidence and assessment
  • Trombley-Brennan Terminal Tissue Injuries (TB-TTI)
  • Differentiating skin failure from pressure injuries and MASD
  • CMS survey readiness, MDS coding, and care planning implications
  • Emerging research and evolving clinical consensus
Clinical Context

Skin failure is recognized as an unavoidable skin change in some individuals experiencing multiorgan failure, systemic hypoperfusion, or end-of-life decline. Evidence supports its distinction from pressure injuries in specific clinical contexts.

Key frameworks include the SCALE (Skin Changes at Life's End) consensus document, NPIAP position statements, and emerging interdisciplinary research on Kennedy Terminal Ulcers and end-of-life tissue injury patterns.

All clinical discussions in the SIG are evidence-based and peer-reviewed. This page is for educational purposes and does not constitute medical advice.

SIG Details

PAWSIC's inaugural Shared Interest Group
Open to PAWSIC Premium Members
Evidence-based discussions and case studies
Active forum led by PAWSIC board members
What's Inside

What You'll Find in the Skin Failure SIG

A curated space for focused collaboration, not general wound care discussion.

Peer Forum Discussions

Ask clinical questions, share challenging cases (fully de-identified), and get perspectives from wound care specialists, DONs, palliative care clinicians, and researchers across care settings.

Evidence & Resources

Curated research, SCALE consensus documents, NPIAP position statements, clinical assessment tools and documentation templates specific to skin failure and end-of-life skin changes.

Webinar & CE Content

Access to PAWSIC's skin failure webinar library, including CE-eligible recordings on Kennedy Terminal Ulcers, SCALE, end-of-life documentation, and regulatory survey readiness.

Survey & Compliance Guidance

Practical discussion threads on MDS coding, care planning documentation, F686 survey tags, and communicating skin failure findings to surveyors, families, and interdisciplinary teams.

Expert Networking

Connect directly with PAWSIC board members, advisory committee clinicians, and nationally recognized wound care experts who specialize in skin failure and end-of-life care.

Shape the Research Agenda

As PAWSIC's inaugural SIG, members have a direct role in identifying practice gaps, proposing position statement topics, and advancing PAWSIC's advocacy work on skin failure standards.

Who Joins

This SIG is for You If You Care About Skin Failure

Anyone involved in wound care, palliative care, hospice, post-acute settings, or regulatory compliance is welcome to join.

WOC Nurses & Wound Specialists Directors of Nursing & Clinical Leadership Palliative Care & Hospice Clinicians Physicians, NPs & PAs Quality Improvement & Compliance Professionals Researchers & Academics Home Health & LTC Clinicians MDS Coordinators & RAC-CT Nurses
SIG Leadership

Meet the Chairs

The Skin Failure SIG is led by nationally recognized wound care clinicians, researchers, and legal nurse consultants with decades of specialized expertise.

Heidi H. Cross, MSN, RN, FNP-BC, CWON, CDP

Heidi H. Cross

MSN, RN, FNP-BC, CWON, CDP

Co-Chair

Heidi is a board-certified Wound and Ostomy nurse and Family Nurse Practitioner currently consulting for long-term care facilities in the Syracuse, NY area and at Strong Memorial Hospital in Rochester. A seasoned legal nurse consultant providing expertise in wound issues and nursing standards of care, Heidi has been published in the Journal of Wound Ostomy and Continence Nursing, the American Journal of Nursing, and the American Nurse Journal, and has lectured on wound and ostomy care regionally and nationally. She holds degrees from Syracuse University and SUNY Upstate University and is a member of the Wound, Ostomy and Continence Nurses Society and the American Nurses Association Legislative Committee.

Cynthia Sylvia, D NURS, MSc, MA, RN, CWCN

Cynthia Sylvia

D NURS, MSc, MA, RN, CWCN

Co-Chair

Cynthia is a legal nurse consultant with over four decades of specialized expertise as a board-certified Wound Ostomy Continence Nurse. She holds a Doctorate in Nursing and a Master of Science in Wound Healing and Tissue Repair from Cardiff University, where she is an Honorary Lecturer. As principal of Cynthia Sylvia, LLC, she collaborates with legal teams to bridge medicine and law in complex wound healing cases. Her contributions span global consensus development on SCALE, academic publishing, support surface standardization, and interprofessional education, advancing standards of care and patient safety at the intersection of clinical practice and legal accountability.

Pamela Scarborough, PT, DPT, CWS, FAAWC

Pamela Scarborough

PT, DPT, CWS, FAAWC

Co-Chair

Pamela has been drawn to healthcare since her teenage years. Her journey in physical therapy has spanned Orthopedics, Sports Medicine, Total Joint and Spine care, Cardiac Rehabilitation, Geriatric physical therapy, and Wound Management. She specialized in wound management with her Certified Wound Specialist (CWS) designation 24 years ago, building a rewarding career providing wound care to patients and mentoring clinicians in the specialty. She has supported healthcare professionals across disciplines in acquiring their Board Certifications as wound specialists.

Pamela was also credentialed for 20 years as a Certified Diabetes Educator (CDE), developing a deep expertise in diabetes prevention and management and its connection to hard-to-heal wounds. Outside of work, she enjoys music, dance, yoga, Pilates, reading, and time with animals and people, and when not traveling, relishes a quiet life in the Texas Hill Country with her husband, Gregory Dean, and her beloved feline companions, Blackfeet and Mister Kitty.

Diane L. Krasner, PhD, RN, FAAN, FAAWC, MAPWCA, WOCNF

Diane L. Krasner

PhD, RN, FAAN, FAAWC, MAPWCA, WOCNF

Board Liaison

Diane L. Krasner is a board-certified wound care nurse (CWCN) with over thirty-five years of experience across the continuum of wound, ostomy, and continence care. She serves as Interim Past President of PAWSIC and is a Fellow of the American Academy of Nursing, Fellow of the Association for the Advancement of Wound Care, and Master of the American Professional Wound Care Association and Fellow of the Wound Ostomy Continence Nurses Society. Dr. Krasner is a widely published wound and skin care consultant, educator, and expert witness.

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