"I would write a letter to the hospital's legal counsel and copy the nursing director and my own Chief-of-Staff what I witnessed, then step aside. It would be out of my hands at that point, as it should be."

Hospitals take privileged information very seriously. Violations could severely and negatively impact reputation, credentialing, and even the hospital's fiscal health (due to fines and other disciplinary measures). Your role in policing this, however, is limited. Hospitals want such indiscretions handled a certain way, and you can assure them they will be by pledging yourself to following established hospital protocol. Today, the argument of 'my word against his or -hers' no longer applies, thanks to electronic medical records which require signing in to them, establishing permanent documentation of it.

"I would notify the nursing supervisor what I saw and request he or she look into it to verify if what I suspected was correct."