LAck of communication still exist

I have a 50 year old gentleman with diabetes admitted to the hospital a week ago Friday.  He had a urinary tract infection and was septic so he landed in the ICU. I went to visit on Saturday, introduced myself and gave them our HIPAA release form and asked  "please keep us in the loop".  I went in again on Monday when he was transferred to the medical unit and had a discussion with the nurse. Very nice, information shared and spoke to my client and asked "please make sure his implanted catheter as he won't need it coming back and we have been trying to get it out for a few weeks now" she replied "we'll take care of it".  I then called the case manager and left her a message with my contact information explaining what I do and how I am involved.  I never heard from her until Thursday when she called tell me he was being discharged that day. She thought she was calling the VNA, (visiting nurses), I quickly told her no we were not the VNA and gave her the VNA that was involved.  I also reminded her about his catheter that needed to be removed. She didn't even know he had a hickman catheter.  When I also discussed that he will go back to have his wound vac placed by the VNA she continued to say that perhaps he needed assessed by the wound clinic. I advised her that he has been going to the wound clinic for quite some time. She did not know he went to the wound clinic.  I asked if she would please confirm his appointment with the wound clinic, make an appointment for the hickman catheter that should have already been taken out.  She said she needed to have the manager call me.  She did and the above things were done. 

Here's the problem NO ONE IS COMMUNICATING!!! simple you would think to just talk to each other but they don't.  Even after being told on a few occasions it was clear she knew nothing about this gentleman being discharged.

Someone like this gentleman could have been back in the system in a heart beat without knowing his history or just talking to him. Imagine talking to the patient!! He is only 50 I didn't spend a lot of time with him because I knew he could talk for himself. BUT no one talked to him.