Everything Is Connected: A Systems View of Skin, Falls, and the Human Condition

There is a new federal audit program making its way through skilled nursing facilities across the country right now. The SNF Validation Program, launched by CMS in early 2026, is reviewing the accuracy of quality data submitted by facilities, and three of its core measures are pressure injuries, falls with major injury, and medication management.

On the surface, it reads like another compliance initiative. Another checkbox. Another set of consequences for facilities that do not document correctly.

But if you look more carefully, what CMS has actually done, perhaps without intending to, is identify the final common pathway of almost every systemic failure in human care. Pressure injuries. Falls. Medications gone awry. These are not random bad outcomes. They are the visible endpoint of invisible systems falling out of alignment. And that distinction matters enormously if we ever want to do better than manage consequences after the fact.

The Body as a System

Let's start where all care starts: the individual human.

Imagine the theoretically "perfect" person: exceptional vascularity, intact sensation, full cognition, strength, mobility, ideal nutrition, strong bones, fast reaction time, robust hydration, stable mental health, a healthy heart, and a metabolism humming along without interference. This person could sit at a desk for six hours, lie on the beach all afternoon, or sleep in an awkward position and never develop a pressure injury. They could stand up quickly, navigate a dark hallway, or step off a curb without incident. They would need very few medications, and the ones they took would not fight each other.

That person is the baseline. The full reserve.

Now begin removing pieces of that reserve, one at a time.

Poor circulation? The tissue can no longer respond to sustained pressure the way it needs to. Diminished sensation? The body stops sending the signals that prompt repositioning. Malnutrition? The skin loses its resilience. Cognitive decline? The awareness needed to self-protect begins to fade. Remove enough of these reserves, not one but several at once, and the threshold for harm drops dramatically. A two-hour chair sit that would be unremarkable for someone with full reserve becomes a pressure injury waiting to happen for someone whose reserve has been depleted by age, disease, and time.

This reframes everything.

We have long talked about "risk factors" for pressure injuries and falls, as if these are isolated variables we can check off on an assessment tool. But perhaps the more useful frame is reserve. What does this person still have? What has been lost? What remains, and how fragile is it?

Working backwards from outcome to reserve, rather than forward from risk factor to intervention, changes the clinical question. It becomes not "is this person at risk?" but "where has this person's capacity to protect themselves been diminished, and what can we do about that?"

Medications: The Double-Edged Reserve

Enter medications, arguably the most complex variable in the system.

Medications exist, at their best, to restore or compensate for missing reserve. The person whose immune system is attacking itself gets an immunosuppressant. The person whose blood pressure is dangerously elevated gets an antihypertensive. The person whose bones have thinned gets supplementation and treatment. Each medication is, in theory, a prosthetic for a failing internal system.

But every prosthetic has trade-offs.

The immunosuppressant that quiets the autoimmune response also quiets the healing response. The antihypertensive that protects the heart creates orthostatic hypotension, that dizzy, unsteady moment upon standing that turns an ordinary trip to the bathroom into a fall risk. The medication that manages one missing reserve creates a gap somewhere else.

And then there is polypharmacy, the reality of many older adults who are managing multiple chronic conditions simultaneously, each with its own medication, each interacting with the others in ways that are not always predictable and are rarely studied together. Add to this the chaos factor of aging itself: not a disease, but a relentless, compounding diminishment of reserve across nearly every system. Skin thins. Muscle mass decreases. Reaction time slows. The kidneys process medications less efficiently. The brain requires more time to integrate sensory input and produce a corrective movement.

The older adult in a skilled nursing facility is, in many cases, a person managing the convergence of all of these forces at once. Compounding reserve loss. Compounding medications. Compounding consequences.

Pressure injuries. Falls. Adverse medication interactions.

These are not failures of individual nurses or individual physicians. They are the output of an extraordinarily complex system operating under enormous strain.

The External System: Where the Body Lives

Now add the second layer: the environment.

Every body exists somewhere. And where it exists shapes what happens to it as profoundly as any internal biology.

The external system, whether home, assisted living, or nursing home, is not a neutral backdrop. It is an active force shaping outcomes. And like the internal system, it has its own reserves and deficits: staffing ratios, architectural design, care philosophy, technology infrastructure, leadership culture, reimbursement pressures, regulatory constraints.

Every outcome is the result of the system that produced it.

What CMS Is Measuring, And What It Isn't

Back to the SNF Validation Program.

CMS is, wisely, measuring the things that are measurable: whether a fall happened and whether it caused major injury. Whether a pressure injury developed. Whether medications were reviewed and whether problems were followed up on. Whether the data submitted on the MDS actually matches the clinical record.

These are legitimate and important things to measure.

But these measure outputs, not systems. They tell us what happened. They do not tell us why, or what the upstream conditions were that made it likely to happen. A facility with the most complex, most medically fragile population in a region will have more pressure injuries and more falls than a facility with a healthier, less depleted population, not because they are providing worse care, but because they are working with systems under greater strain.

This is not an argument against accountability. It is an argument for honesty about what accountability, alone, can achieve.

A New Conversation

Here is what I am proposing. Not a throwing up of hands. Not a resignation to "this is just how it is." A different conversation.

One that begins with human design, not regulatory compliance.

One that uses skin health and mobility, often the last reserves to go, the final visible signal that internal and external systems have lost their alignment, as the proxy measure we actually care about: not a checkbox, but a window into the whole person and the whole system supporting them.

One that asks, before we build another assessment tool or add another documentation requirement: what does this person need in order to remain whole? What reserves remain? What can we restore? What can we protect? And what does the environment around them need to look like to support that?

We have more knowledge now than we have ever had. We understand wound healing at the cellular level. We understand biomechanics and fall prevention. We understand pharmacokinetics in aging populations. We understand the neuroscience of cognition and the sociology of institutional living. We have data. We have technology. We have people who have spent entire careers in this work.

What we have not yet done is bring all of that knowledge together into a coherent, human-centered system, one designed from the person outward, rather than from the regulation inward.

Jeanine Maguire, PhD, MPT, CWS, FCPP

President, Post-Acute Wound & Skin Integrity Council (PAWSIC)

PAWSIC.org is dedicated to advancing wound care, skin health, and the systems that support human dignity in care settings. Views expressed are those of the author.