Florida could have fined All Children’s millions for late reports. It went with $4,500.

Late last year, Johns Hopkins All Children’s Hospital made a striking admission to state regulators: It had failed to report at least nine cases where its care had hurt patients.

Worse, All Children’s had gotten in trouble for not disclosing similar issues just months before. In that case, regulators learned that the hospital had left a surgical needle in a child’s chest by reading the Tampa Bay Times. The hospital was suddenly admitting its problems went far deeper.

State law gave the regulators the power to send All Children’s a punishing message with a fine that could have reached into the millions.

Instead, regulators fined All Children’s a total of $4,500.

Experts and health lawyers described the amount as surprisingly low and unlikely to register on the balance sheet of an organization the size of Johns Hopkins.

“That’s lunch for an executive meeting,” said Robert Field, a Drexel University professor and expert in health care regulation.

George F. Indest III, an attorney in the Orlando area who represents assisted living facilities and home health providers, called the figure “shocking.”

“You would think that for the more critical care facilities, where they are doing surgeries and trying to save lives on a daily basis, it would be a lot more serious and the fines would be more serious,” he said.

A spokeswoman for the Agency for Health Care Administration did not answer repeated questions about how the fines were determined. She declined multiple requests to make Secretary Mary Mayhew or another official available for an interview.

“We take our responsibility to hold facilities accountable for patient care very seriously,” Mayhew said in a statement.

The agency is still reviewing other findings from a recent inspection of All Children’s, which identified widespread problems in the hospital’s governance structure and quality improvement procedures. More fines could be coming, the agency spokeswoman said.

[ Read the findings from the January inspection: New federal report details widespread problems at All Children’s ]

A spokeswoman for All Children’s referred questions to the state.

The health care agency licenses all hospitals in Florida. But short of the extreme step of revoking or suspending a hospital’s license, it mostly enforces its rules through citations and fines.

Nonetheless, a Times analysis of the 377 fines given to hospitals since 2014 that were posted to the agency’s website shows the way the agency handled All Children’s was not out of character.

Just 10 percent of the fines topped $5,000. The seven highest individual fines were between $50,000 and $80,000; they were issued to hospitals that failed to submit financial reports or patient data to the state on time.

Even the larger fines pale in comparison to most hospital budgets. All Children’s profit was $50 million in the fiscal year that ended in June 2017, its most recent available tax forms show.

All Children’s has been under scrutiny since November, when a Times investigation detailed problems in the hospital’s heart unit, including a sharp increase in deaths and complications among surgery patients.

[ Read the investigation: Johns Hopkins promised to elevate All Children’s Heart Institute. Then patients started to die at an alarming rate. ]

[ More coverage: State, federal officials missed warnings at All Children’s heart unit ]

In the days and weeks that followed, All Children’s leaders notified the state about nine “adverse incidents” that had happened at the hospital since 2016, according to the recent citations.

None had been reported to the state in real time.

Details about the incidents were not available. But in February, a hospital spokeswoman told the Times the hospital had reported a total of 13 adverse events to the state, six of which involved patient deaths.

State law requires hospitals to quickly report serious adverse incidents, which include surgeries performed on the wrong patient or body part; procedures to remove a foreign object left in a patient’s body; or any time a patient’s medical care causes death, disfigurement or brain or spinal injury.

Reports must be filed within 15 days.

In one case, All Children’s was 921 days late in filing the proper paperwork, records show.

The total possible fine for not reporting an adverse incident is capped at $5,000 for an unintentional infraction and $10,000 for a repeated unintentional infraction. For an intentional infraction, the fine can be $25,000 a day, capped at $250,000.

All Children’s was fined $500 per incident for nine violations.

State law includes guidelines for determining the size of fines. Regulators should take into account “actions taken by the licensee to correct the violations or to remedy complaints” but also consider “any previous violations” and “the probability that death or serious harm to the health or safety of any person will result or has resulted.”

Former Agency for Health Care Administration Secretary Alan Levine, who held the position from 2004 to 2006, said All Children’s may have gotten a lighter penalty because it acknowledged the problems before regulators visited the facility.

“Self reporting shows that they’re trying to clean up some of their historical issues,” he said.

The hospital had already gotten in trouble for failing to report adverse incidents.

After the Times reported in April 2018 that physicians left a surgical needle in a child after a 2016 procedure, state regulators cited All Children’s for not reporting the incident within 15 days. They also cited the hospital for failing to report another adverse incident, the details of which were never made available.

[ Read: All Children’s never told state about needle left in baby ]

Neither citation resulted in a fine.

At the time, All Children’s top executives told the Times that they would comply with the state’s findings and consider seeking guidance to ensure future compliance was “absolute.”

“We want to stress to our community that we have been modifying, updating and improving our processes during the two years since these events and we feel confident that these measures will ensure better care and better communications for our patients and families,” the hospital said in a May statement.

The state determined in June that All Children’s had fixed the problems, inspection reports show. When fining the hospital in December, however, the state indicated that the problems it had previously required a fix for were “not corrected.”

It was not clear if All Children’s challenged the December fines.

Public documents show the state health care regulator has fallen short on enforcing the adverse incident laws in the past.

An internal audit from 2014 found that the agency was not making sure adverse incident reports were submitted on time. It also found that facilities were not being fined for late reports.

The agency may still take action against All Children’s, a spokeswoman said in an email.

During a visit to the hospital in January, state inspectors found a number of shortcomings, including that the hospital’s governing board had not exercised proper oversight, that leaders had failed to analyze results across departments and that there had been a lack of communication between risk management and other units.

Some of the issues could draw fines. For example, inspectors found six instances in which All Children’s could not demonstrate it had informed patients or their representatives about their rights and responsibilities. Hospitals can face a penalty of up to $25,000 each time they fail to do so.

[ Click here to read all of the Times’ coverage of All Children‘s Heart Institute ]